Strategies to Optimize Your PBM Dollars
September 27, 2022
By: Sylvia Flores, Group VP of Operations, MC-Rx
As drug cost and utilization of specialty products increase, it is critical to meticulously assess your member’s utilization patterns and outline a custom strategy that allows you to provide the best clinical outcomes to your members at the lowest possible cost.
In MC-Rx our approach to cost containment and cost reduction strategies is customized to help you achieve that critical balance. It is evident, nowadays, that the one size fits all approach is not the best strategy to follow.
Let’s review some important considerations when evaluating and optimizing your Pharmacy Benefit Manager (PBM) Services:
- Transparency – when contracting your PBM services, it is critical to understand how are you going to obtain the lowest net cost, and which are the fees associated with the services to be contracted. Focusing only on the dollars to be saved, without knowing the source of those savings, can be a misleading approach not bringing overall value to you and your members.
- Lower Cost Approach Our team of Pharmacy Doctors design formularies that include the best clinical alternatives based on efficacy and safety, while also evaluating the drug cost and manufacturer discount negotiations. Focusing only on savings driven by manufacturer’s rebates may result in unnecessary costs that could be offset by an effective formulary design.
- Drug Management Tools –It is perceived that limiting access to medications may help achieve the lowest net cost, but this is not entirely true for many reasons: 1) The use of non-clinical Prior Authorization Strategies, may limit the rebates obtained from drug manufacturers. It is important to evaluate if the utilization reduction with the PA will offset the economic benefit projected from rebates. 2) It is also important to evaluate how the timely use of a medication may help reduce costs associated with other medical interventions, such as; hospitalizations, emergency visits, dialysis, etc. For these, in many cases, the costs surpass the cost of the medication.
- Drug Discount at the Pharmacy Network Contracts– PBMs must ensure a healthy relationship with their providers in order to obtain the best outcome for their clients. The PBM’s ability in negotiating drug discounts with their Pharmacy Network is critical in establishing a cost effective Pharmacy Benefits Program.
- Cost Containment Strategies – Nowadays it is important that PBMs provide cost containment strategies, such as Smart Co-Pay Programs, Personal Importation of Medication support, Alternative Funding Programs, Discount Cards, etc. As the cost and utilization of specialty products and drugs for chronic conditions increase, manufacturers and independent entities provide an increasing number of programs to support and drive access to patients in need. The combination of these programs with the benefits offered by employers and insurers increases the access to innovative medications that will improve your member’s quality of life at an affordable cost for both. Many of these programs could result in $0 or a very low copay for your member and significant cost reduction for you as the payer.
Finally, discussing with your PBM provider the way they handle the above strategies is critical, asking the right questions and truly evaluating the entire program offerings, beyond rebates, is imperative to drive member satisfaction at an effective cost.
Contact us to discuss your alternatives and to receive a proposal of our services, especially design for you.
URAC accreditation reflects ProCare Rx’s commitment to achieving and maintaining the highest quality, member engagement and experience, and operational standards for PBMs in the industry
Mental health parity and medication adherence
Understanding GLP-1 Medications The landscape of obesity management is evolving, with GLP-1 receptor agonist (RA) medications emerging as a significant player. These FDA-approved drugs have proven effective in helping individuals lose weight, prompting a shift in how they are viewed and covered by health plans. However, the cost implications and strategic decisions surrounding these medications require careful consideration by employer groups and their members. The Case for GLP-1 Medications GLP-1 RAs, originally developed for diabetes management, have shown remarkable efficacy in weight loss. With the growing prevalence of obesity and its associated healthcare costs, there's increasing pressure on health plans to cover these medications. Despite their high cost—annual retail pharmacy expenses can exceed $10,000 per patient—GLP-1 RAs offer potential downstream savings by reducing obesity-related comorbidities such as diabetes, hypertension, and cardiovascular disease. Balancing Coverage and Cost Historically, weight loss medications were deemed "lifestyle" drugs and excluded from coverage. However, the rising popularity of GLP-1 RAs and their demonstrated benefits are challenging this perspective. For plan sponsors, the decision to cover these medications involves balancing the high upfront costs with the potential for long-term savings on medical expenses related to obesity. Cost-Containment Strategies For payers choosing to cover GLP-1 medications, several cost-containment strategies can be employed: Formulary Management : Deciding on the placement of these medications within the formulary is crucial. Options range from not covering the drugs to placing them on a high-cost tier with patient cost-sharing. Prior Authorization and Step Therapy : Implementing these measures ensures that only patients with a proper diagnosis (e.g., ICD-10 code for obesity) access these medications, preventing misuse and overutilization. Prerequisite Programs : Requiring participation in wellness or nutrition programs before approving weight loss medications can encourage lifestyle modifications that complement pharmacological treatment. Specialist Restrictions : Limiting prescriptions to weight loss specialists, such as bariatric doctors or endocrinologists, ensures appropriate therapy and monitoring. Duration Limits : Establishing treatment guidelines, such as discontinuing medications if a target weight loss is not achieved within six months, helps manage long-term costs. The Role of Brokers and Employer Groups Brokers play a pivotal role in guiding employer groups through the complexities of covering GLP-1 medications. Understanding the cost-benefit dynamics and available cost-containment strategies enables brokers to provide informed recommendations that align with their clients' financial and health objectives. Employer groups, in turn, must weigh the potential benefits of covering these medications against their budgetary constraints and the overall well-being of their workforce. Member Education and Engagement Effective communication with members is essential to ensure they understand the coverage options and adhere to prescribed treatments. Educational initiatives can include: Patient Communication Programs : Providing information on medication adherence, compliance, and lifestyle modifications. Continuing Education : Ongoing programs to keep members informed about the benefits and proper use of weight loss medications. Monitoring and Support : Utilizing pharmacy and medical data to track outcomes and adjust strategies as needed. Balance the Scale with Expert Guidance from MC-Rx The adoption of GLP-1 medications for weight loss represents a significant advancement in obesity management. However, the high costs associated with these drugs necessitate careful planning and strategic implementation by brokers, employer groups, and members. By employing robust cost-containment strategies and prioritizing member education, health plans can navigate the financial challenges while delivering meaningful health benefits to their populations. MC-Rx, as a full-service pharmacy benefits manager, offers the expertise and tools to help clients optimize their coverage decisions and manage the complexities of incorporating GLP-1 medications into their health plans. Here are just a few of the GLP-1 strategies we use to shield our clients from excessive costs: Implementation of Drug Management Tools, which is critical to ensure proper utilization for GLP-1s. Strategic Benefit Design, which also protects clients from improper GLP-1 utilization. Clear Member Communication, which is crucial for proper adherence and compliance. When implemented with an existing client, the above-listed strategies helped them achieve $382,000 in cost avoidance for GLP-1s. With the right approach, the benefits of these medications can be realized, contributing to better health outcomes and potentially lowering overall healthcare costs in the long run. For more information on managing GLP-1 medications and other pharmacy benefits, reach out to an MC-Rx expert today .
Mental Health Parity and Medication Adherence
MC-Rx, powered by ProCare Rx, has been notified by the Academy of Managed Care Pharmacy (AMCP) of the acceptance of their abstract, “Improving Adherence to HIV PREP via a PBM-Driven Educational Intervention” , for presentation at AMCP 2024 Conference in April.
Exploring the rising costs and demands of weight-loss medication and how to combat those costs, significantly lowering drug costs for payors and increasing access for patients who need them.
A message from Marileny Lugo, President, MC-Rx
A message from Marileny Lugo, President, MC-Rx
To decrease the burden on healthcare costs, at MC-Rx we strive to create awareness by educating our community regarding the importance of prevention.
Increased medication adherence has been linked to better clinical and financial outcomes.
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