Top 3 Things You’ll Learn
- What to expect when an insurance carrier changes PBMs
- What options employers have when their carrier changes pharmacy benefits partners
- How employers can take back control when they don’t want to transition PBMs with their insurance carrier
If a health insurance company decides to make changes to its PBM arrangement, every employer in its client base will feel the impact.
Employers who bundle their pharmacy and health benefits under one health insurance provider – a “carved in” model – may feel left in the dark when this decision is made, and uncertain how the new PBM will affect their plans and their members. These tips can help employers prepare for – and capitalize on – the transition.
The Reality of a Carrier-PBM Transition
Employers in a carved-in arrangement will see changes to pharmacy networks, drug formularies, specialty and mail order pharmacy dispensing requirements, member websites, and member communications – as these features are updated to reflect the new PBM arrangement.
Members will feel the impact of these changes, as customer service numbers and experiences change, and sensitive processes like prior authorizations change to reflect the new partner’s processes.
The transition process is very similar to what happens when a self-funded employer selects a new PBM. But in this case, the employer was not involved in the decision, and while it may have been the best option for the larger health insurance carrier and its broad book of business, it may not serve the best interests of each individual employer.
When this happens, it’s important for employers to be proactive – to advocate for change on their own terms, with attention to their unique business goals and member dynamics.
Make Lemonade from the Lemons
Rather than sit back and wait for this unwanted disruption to hit, employers have another option. Fully funded or self-funded employers in carved-in arrangements can act now to ensure their pharmacy benefits program is serving their plan and their members well. By self-funding and carving-out their pharmacy benefits, employers can flip the script and make a better change on their own terms. For some employers, having the power to choose what’s best for their company, their employees, and dependents is vital to managing their own financial pressures and employee needs.
With change and disruption inevitable, why not take the opportunity to negotiate a client-friendly contract and improve the value of the benefits plan in the process? Why not allow employers to select the plan design and clinical program options that address their member population and their specific financial and healthcare goals? This would give HR leaders peace of mind that the change was worthwhile because they got to choose their own benefits program – one designed for their individual membership, not set for them based on the carrier’s global book of business.
How to Evaluate Pharmacy Benefits Opportunities
To best understand each employer’s options and find out if carving-out makes sense, we recommend these steps:
√ Initiate a financial analysis to confirm contract terms serve the best interest of the plan – based on member utilization and demographic data, that the plan’s prescription drug rates and rebates are competitive, and that the clinical management strategies are effective and aligned to the employers goals.
√ Compare the alternatives: When contrasting the economics of the current pharmacy benefits arrangement to other options in the market, the evaluation must provide a real apples-to-apples comparison. This is difficult to manage without support from industry experts who focus entirely on making these complex comparisons. RxBenefits curates a best-in-class Marketplace where traditional and transparent PBMs compete for your business. Here, clients can choose from comparable, normalized PBM data, along with additional cost containment options, for a plan designed for their specific needs.
√ Make changes (if warranted): With the data in hand, brokers and employers can choose a partner that provides pharmacy-specific expertise, client-friendly contracts and tailored, transparent clinical solutions.
As the industry’s first and leading pharmacy benefits optimizer (PBO), RxBenefits streamlines the process to protect self-funded employers’ interests more effectively.
We can review existing pharmacy contracts (if they exist) and claims files to provide full visibility into plan’s current value, and opportunities to optimize the plan to meet cost-containment and member access goals.
