Specialty Drug Rebate Optics Putting Your Clients at Risk

Top 3 Things You’ll Learn

  • How PBMs define specialty drugs in their pharmacy benefits contracts
  • Why employer-sponsored plans need clear pharmacy benefits contract terms
  • Five contract pitfalls posing a risk to pharmacy benefits rebate performance

Unbeknownst to some, there is not a universally used specialty drug definition or specialty drug list that applies to pharmacy benefits contracts. Each pharmacy benefit manager (PBM) maintains its own specialty drug list and its own specialty drug contract terms. Furthermore, each PBM may have many iterations of their contracts. While there may be some standard language used across the board, each contract contains negotiated terms that can significantly alter specialty drug rebates and vary the contract’s rebate performance in ways clients do not understand.

These 5 pharmacy benefits contract optics can pose a big risk to your expected specialty drug rebate performance. #specialtyRx

As you negotiate a competitive pharmacy benefits contract for your self-funded clients, it’s important that you clarify any vague or misleading language, especially around specialty drugs. In our experience, these five areas can pose some of the biggest risks to your clients’ contract and can significantly impact their expected rebate performance:

  • List of specialty drugs on the formulary
  • Limitations related to the fulfillment channel used
  • Restrictions according to days’ supply
  • Not properly modeling the value of any drug exclusions from the rebates
  • Altering rebates based on claims utilization

By protecting your self-funded clients from these contract optics, you will help ensure that they receive the proper specialty drug rebate dollars available to them.

Watch our on-demand webinar to discover other contract and clinical best practices to help your self-funded employer clients manage their specialty drug costs.

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