How Health Insurers Are Forcing Employers to Use the Insurers’ Pharmacy Benefit Management Service

The money-driven world we live in can often leave us feeling cheated by the very entities we rely on. That doesn’t have to be the case with your pharmacy benefits plan. In 2020, Bloomberg news featured a story on how employers’ experiences with carving-out pharmacy benefits from their medical insurance carrier and the extent that insurers are going to keep their clients from unbundling their benefit arrangements.

Wagstaff, Inc., a 500-employee manufacturing company based in Spokane Valley, Wash., was one group featured in the article. Wagstaff leaders tried to gain control over their pharmacy plan but faced numerous hurdles from their then-carrier, Premera Blue Cross. They eventually switched health plan administrators altogether, turning to UnitedHealthcare for the 2019-2020 plan year. The switch allowed Wagstaff to carve-out pharmacy benefits and contract with an independent pharmacy benefits optimizer, RxBenefits Inc.

Read our case study to find out how partnering with RxBenefits under the carved-out PBO model helped Wagstaff leaders rectify their plan’s pharmacy risk areas before costs spiraled. Hint: It was even better than expected; actual plan costs were 20% lower than projected in their initial pharmacy plan analysis.


Excerpt from the Bloomberg Law article:

The savings for small employers that are able to use a PBM of their choosing can be substantial.

Wagstaff Inc., a 500-employee manufacturing company in Spokane Valley, Wash., switched from using Premera Blue Cross as its health plan administrator to UnitedHealthcare for its 2019-2020 plan year, Wade Larson, director of human resources, said in an interview.

The switch allowed Wagstaff to contract with an independent pharmacy benefit manager, RxBenefits Inc., which enabled the company to develop strategies for controlling pharmacy costs, especially high-cost specialty pharmaceuticals, he said.

“The specialty drugs are killing us all,” Larson said.

In previous years, Wagstaff experienced double-digit increases, with pharmaceutical costs a major contributor, Larson said. The company expects to reduce its pharmacy spending from $957,000 under Premera, which used Express Scripts, to $754,000 in the 2019-2020 plan year using RxBenefits, he said.

Keeping pharmacy benefits as part of Premera’s plan made it harder for the company to know how much it was spending on pharmaceuticals and how much on medical claims, he said.

“I could not get the best drug deals, I could not negotiate anything different, I couldn’t go shopping, and it was very restrictive,” Larson said of Premera’s drug benefit.

Under its current pharmacy arrangement, the company has the ability to negotiate prices for both generic and specialty drugs and change its benefit design, Larson said.

Premera spokesperson Dani Chung said in an email that the insurer’s approach “is to deliver an integrated pharmacy and medical program. We believe that this allows us to deliver a better customer experience and control costs. “Integrating these benefits allows for the best clinical decision-making possible, producing better outcomes and more savings for our customers.”

Premera does support “a few customers” in carving out pharmacy benefits, Chung said.


Reproduced with permission. Published Jan. 22, 2020. Copyright 2021 by The Bureau of National Affairs, Inc. (800-372-1033)


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