In today’s era of exorbitantly high health care costs, it can be hard for anyone to catch a break. When working with pharmacy benefit management (PBM) programs like CVS Caremark and Express Scripts, clarity is key to preventing frustrated, financially-strapped employees – and your bottom line.
What’s a PBM?
Basically the ‘middle man,’ PBMs function as third-party administrators for prescription drug programs. Often bigger than the companies they negotiate drug deals for, they not only process claims, but develop/maintain formularies, negotiate prices and coverage percentages, discounts and rebates, pharmacy contracts, and more.
How to Make Sure Everyone’s Getting What They Paid For
Following the 2016-2017 EpiPen debacle, where individuals on PBM plans found themselves paying $600 for a single EpiPen (it was later discovered drug intermediaries, including PBMs, pocketed half the dough), there's been lots of push-back for transparency in the pharmacy benefit management business.
The Clear Path to Finding a Good Plan:
When negotiating 2018 benefits, look for transparency in contracts to better track hidden costs. Arming yourself with this information can help you educate workers on paths to prescription savings. Superior PBMs offer…
- Transparency in contract terms.
Plan sponsors are far more satisfied with programs that have transparent pricing: Those that allow access to all data, disclose all revenue sources and eliminate hidden cash flows.
- Models that frown upon ‘spread’ pricing.
The difference between what a plan is billed and the amount the pharmacy is reimbursed – ‘the spread’ – is where less-satisfying programs often make money.
- Plans with a fair appeals process.
So doctors/patients can achieve proper treatment.
Pharmacy benefit management giving you a headache? Minnesota Comp Advisor is here to help.