3. The explosive rise in GLP-1 use (and uses): GLP-1s, which carry hefty price tags, were originally approved for the treatment of diabetes, although several have gone on to get expanded indications for weight loss and certain cardiovascular conditions. They already account for more than $38 billion in annual spend, but many are seeking approval to treat even more indications for a range of conditions including NASH/MASH, sleep apnea, Alzheimer’s, and psoriasis. This is likely to increase their utilization significantly, including for weight loss, which exists as a comorbidity with many of the new indications.

These are serious challenges, but by tapping into proven, expert-backed strategies for pharmacy benefit optimization (PBO), benefits advisors can help clients tame drugflation, unlock savings, and improve plan sustainability. Pharmacy benefit optimization is a comprehensive approach to managing an employer’s pharmacy spend to the lowest net cost while delivering superior health outcomes and an exceptional member service experience. It goes beyond just negotiating drug discounts and rebates and focuses on strategies to address contract terms and guarantees, formulary and utilization management – particularly for high-cost specialty medications – and clinical interventions. Additionally, pharmacy benefit optimization seeks to simplify plan design and improve member education to ensure employees utilize their benefits effectively. A pharmacy benefit optimizer takes a comprehensive approach to managing an employer’s pharmacy spend to lowest net cost, while delivering superior health outcomes.

3 key strategies for benefits advisors looking to help their clients optimize their pharmacy benefits:

2. Focus on the right details: Aggressive utilization management can help curb utilization, but can often come at the cost of member satisfaction. However, with nearly 50% of plan cost coming from just 2% of members using high-cost drugs, thoughtfully designed, clinical management with the right processes in place can help significantly reduce plan costs without large scale disruption. However, traditional PBM programs are often automated and can lead to inappropriate prescriptions – such as those for off-label use – slipling through. And small to mid-sized employers often don’t have the scare or leverage to be able to get high-touch service. Advisors looking to help employers better manage costs can partner with a PBOs that offer human-led clinical management with independent PharmDs. In addition, it’s important to seek out carefully applied management tools such as prior authorization requirements, diagnosis documentation, and prospective and retrospective reviews to ensure appropriate prescribing and dosing particularly for expensive drug categories such as GLP-1s. Without proper clinical review, up to 40% of GLP-1 prescriptions are for off-label use, RxBenefits data shows. By working with a partner with no misaligned financial incentives and conducting an objective analysis of medical necessity, dosing, and appropriateness of therapy, benefits advisors can ensure their clients' members receive the most cost-effective treatment option.

3. Ensure your pharmacy benefits partner is working for you:  Traditional PBMs often have contracts with pharma manufacturers that can lead to high-cost brand drugs receiving preferred placement on formularies, even when lower-cost, therapeutically comparable alternatives are available. As benefits advisors are likely aware, the Federal Trade Commission (FTC) recently accused the largest PBMs of doing just that for brand insulin, leading to higher costs for employers and members. PBMs often have rebates or other incentives to place higher-cost medications in a preferred formulary position. Tightly managing formularies is key to pharmacy benefit optimization. The advisor’s PBO partner can negotiate with the PBM on a client’s behalf to remove low clinical value drugs from the formulary and include equally effective, lower-cost alternatives. Requiring formulary equivalence (or preference) for biosimilars over their patent-expired, branded “reference products” will also save employers and society billions.

Benefits advisors today are navigating a complex pharmacy benefits market with many opaque practices and hidden pitfalls that can make it difficult to identify the right solutions to recommend to clients to help them make more strategic decisions for sustainable savings and be able to offer robust benefits long-term. Carefully considering a few key areas can turn challenges into opportunities for lasting value, long-term relationships and a strong book of business.

Mark Campbell is Chief Pharmacy Officer at RxBenefits.