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Life Health > Health Insurance > Health Insurance

Pharmacy Benefit Managers Have Changed

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The U.S. pharmaceutical market has changed dramatically in the past five years, and that means pharmacy benefit managers are having to change.

Experts expect U.S. spending on medication to reach $370 billion to $400 billion on a net price basis in 2020. Drug spending has already reached 20% of overall health care budgets, with costs rising annually. In part, this is due to an aging population, new specialty medications and increased utilization.

(Related: GOP Health Bill Kept Secret From Senators Assigned to Write It)

However, poor adherence to treatment protocols and errors within the system generate negative health consequences for patients while impacting health care expenditures.

There is a significant need not only for transparency and ethical conduct amongst PBMs, but a clear requirement to limit incentives to fill prescriptions to simply increase profits and shareholder dividends, regardless of health outcomes and related consequences.

Since 2012, we’ve identified five imperatives for PBMs, which are based on industry needs and customer and consultant requests. These encompass:

  • Flexibility: Brokers, consultants and plan sponsors are no longer looking for several plan options to choose from. They want prescription plans customized to meet their specific and changing needs. PBMs must accommodate this need and do so effectively.

  • Transparency: Lawmakers have proposed legislation that mandates transparency among PBMs in regards to rebates, discounts and hidden incentives that the top PBMs enjoy. Without this transparency, the public’s understanding of why prescription drugs prices continue to rise is limited to list prices, fictitious discount rates and the price we see at the pharmacy counter.

  • Education: Instruction and insights must be conveyed, particularly at the plan sponsor and member levels. To enhance member engagement and ultimately improve health outcomes, we must teach members about specialty and personalized medicine options, as well as generic alternatives and the importance of adherence to treatment protocols.

  • Clinical Advancement: As it evolves, the PBM community must focus more on personalized medicine through pharmacogenetics. Pharmacogenomics studies how an individual’s genetics and metabolism influence their response to specific medications. This provides proactive insight on the effectiveness of a medication in a given patient. This prevents waste associated with medication trial and error and increases positive therapeutic outcomes.

  • Pure Pass Through: Many small to mid-sized PBMs, like BeneCard PBF, respect public concern regarding the business practices of larger PBMs. In response, we offer pure pass-through programs. We’re giving 100% pass-through on rebates and bill the plan sponsor exactly the same amount that is paid to the pharmacy, eliminating spread.

The issues of increasing costs and adverse health reactions will continue to take a toll on plan sponsors and members alike if PBMs do not take action.  We urge other PBMs to follow suite and focus on complete transparency, member safety and member well-being. PBMs can and should play a vital role in improved member care and cost control simply by taking an ethical, member-focused approach.

— Read Anthem Sues Express Scripts, Escalating Pharmacy Dispute on ThinkAdvisor 


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