April 7, 2017

3 Reports You Need from Your Pharmacy Benefits Manager

Artemis Health
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Artemis Insight

Pharmacy benefits are one of the most complex, confusing systems for HR professionals to manage. It’s confusing for members too – they don’t understand why medications are so expensive or how their benefit works. Working closely with a Pharmacy Benefit Manager (PBM) can be a great way to monitor effectiveness and decrease utilization costs without compromising quality member care.

Artemis Health wants to help you better understand how these systems work and what you can do to navigate your relationship with your PBM.

First, some background. What exactly do PBMs do?

  • They are claims adjudicators – pharmacies “process” claims through the PBM on behalf of employer groups and insurance companies
  • They determine eligibility
  • The manage and apply formularies (lists of approved medications for a given plan)
  • They assign the copays that the member is charged at the pharmacy
  • They pay the pharmacy for the balance of the claim
  • They review and approve prior authorizations

Essentially, they function very much like a health insurance company, but they only tackle the pharmacy benefit. They are highly profitable businesses, and often get rebates for expensive drugs that they aren’t required to share with the employer. Sometimes they do share rebates, and sometimes they don’t. They act as a middleman, which can lead to a lack of transparency. It’s up to employers to ask their PBM for data and find potential areas for cost savings.

Even if you’re doing everything right, there is still overspending in your Rx benefit.

  1. If you have 8,000 employees or more
  2. And have a step therapy in place
  3. And have a multi-tiered formulary
  4. And have 100% rebate pass-through

You still likely overspent by 16% on pharmacy benefits!

You can take action today by asking for three items from your PBM:

  1. A report that shows:
    a. Drug name and strength
    b. Number of prescriptions
    c. Quantity dispensed
    d. Days’ supply
    e. Costs (including patient copay and plan paid amount)
  2. Completed prior authorization forms used to approve medications costing more than $3,000/dispense
  3. A listing of rebates collected and a listing of those shared with your company

This will get you started not only on finding wasted Rx spending, but also on a transparent and open relationship with your PBM. And if you find these reports difficult to understand, communicate or share, let Artemis help. Our benefits optimization platform makes it easy to identify overspending, and our expert staff can help you tell the right story about your benefits.

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