Are PBMs playing games with your pharmacy benefits contract? There’s one way to find out.

When pharmacy benefits managers and insurance carriers play games with your clients’ contracts, a quick comparison of numbers on a spreadsheet won’t help you make the best recommendation. The tricky fine print behind the numbers completely changes the costs for employers.

Benefit advisors looking to clarify vague language and create a quick apples-to-apples comparison can take important steps to evaluate clients’ current and future benefits opportunities. In this article, we’ll share what to look out for when comparing programs, why it is important to look at your client’s data directly, and when it’s time to reach out for the support of industry experts.

Look out! Common pharmacy benefits contract pitfalls ahead

Every day, it feels like a new contract tactic is invented to hide costs from clients by using vague language — for example, new rebate exclusions and re-bucketing of claims for reconciliation. Digging into the contract and claims data for an individual plan will surface what’s missed when the focus is on the benefits cost alone, instead of net plan spend.

For example, benefits advisors should determine how generic drugs are defined in each contract — and how that will impact the plan’s performance. PBMs may create their own definitions, especially common with single-source generics. A contract with clear drug classifications may not show the lowest number on the spreadsheet but ultimately may save on actual plan costs. When it comes to plan performance, understanding how claims move around behind the scenes allows you to create a more accurate projection for each contract.

Promised rebates are another way to make a contract number appealing to plan sponsors, but exclusions hidden in the contract language could keep your clients from cashing in on those promises.

• Do you know the impact of multi-source brand claims being excluded from rebate guarantees?
• Do you know what your client can change within their plan in a year without nullifying their guarantees?
• Will the PBM honor the price quoted if enrollment size or utilization increases?

It takes a team to find valid savings in pharmacy benefits contracts.

A financial analysis can give chief financial officers exactly what they’re looking for to evaluate plans for hidden costs, wasted spending or other opportunities to cut plan costs.

Diving into the fine print requires experience with PBMs and claims data. Combining expert financial, clinical, and contract knowledge, a benefit advisor can find the best approach for each unique client to meet their savings a member access goals.

The analysis is particularly valuable when it includes specific claims data and contract terms. Here, a benefits advisor may notice important differences between effective rates and expected performance. An outlier claim may be driving plan costs up, or a manufacturer copay assistance program may artificially inflate performance. Assessing renewal offers can show the expected performance and any potential gaps.

Is your client’s pharmacy benefits arrangement competitive? 

At RxBenefits, we see the contracts and claims of thousands of clients and prospective clients every year, and our expert teams work together to weed out common contract pitfalls each day. We’ll compile all the data and essential nuggets of information into an easy-to-understand and highly compelling report. Not only will you see projected savings and plan recommendations, we’ll also provide background on how we arrived at these numbers—giving you total clarity into what’s behind the spreadsheet and the tools you need to communicate with your clients.

• Know exactly how your client’s current plan is performing against the contract
• Uncover opportunities to deliver meaningful savings via multiple PBM offers through our Marketplace
• Be equipped to clearly explain which plan will serve your client best