RxBenefits Addresses Significant Gaps in Pharmacy Benefits Industry with Launch of Pharmacy Benefits Optimization (PBO) Category

Company establishes new category to help employee benefits consultants and their self-insured employer clients access and deliver an affordable, best-in-class pharmacy benefit that drives down overall healthcare costs

RxBenefits, the industry’s first and only technology-enabled pharmacy benefits optimizer, announced today the launch of a new category of pharmacy benefits management: pharmacy benefits optimization (PBO). As it enters its 25th year helping employee benefits consultants meet the unique needs of their self-insured clients, the company is formally bringing the PBO model to the market as a direct response to industry gaps that result in employers significantly over-paying for pharmacy benefits.

“In the current pharmacy benefits ecosystem, consultants and self-insured businesses are on their own. There is no body or agency to oversee pharmacy benefits costs and to ensure that every member has access to the right medications at the right time and for the right price,” said Bryan Statham, CEO of RxBenefits. “The PBO model is essential to filling the gaps. RxBenefits is the only pharmacy benefits partner that acts independently of Big Pharma and uses advanced data science to advocate in the best economic and clinical interest of self-funded employers and their members – and we are excited to usher in a new era in the pharmacy landscape. The PBO model gives consultants and their self-insured clients greater insight into their pharmacy plan performance data and a seat at the negotiating table, substantially reducing costs while increasing value for members.”

Traditional pharmacy benefits strategies no longer meet the needs of the market. The industry is facing a year-over-year increase in the price of medications, skyrocketing costs, and use of specialty drugs and other high-cost, low-clinical value medications. Because the pharmacy ecosystem and pricing structures are opaque, the forces driving price increases have remained poorly understood. Moreover, pharmacy is one of the most utilized aspects of any health plan: more than half of plan members utilize their pharmacy benefit, averaging ten prescriptions per year. Additionally, 1 in 10 individuals have a chronic condition that may be targeted for treatment with the emerging class of orphan drugs, which average more than $150K per patient per year. Just one unexpected specialty pharmaceutical claim can financially devastate a pharmacy benefit plan.

Murky contracts that bundle medical and pharmacy benefits are the status quo, but are impossible to understand and reconcile. In order for a pharmacy plan to meet the needs of self-funded employers and their members, it needs to be carved out from the overall healthcare benefits plan and managed directly. Recognizing the need for a transparent, data-driven, and hands-on approach to pharmacy benefits, RxBenefits created the PBO model which optimizes three key areas of pharmacy benefits plans:

  • Contract Management: By leveraging market-leading purchasing power that rivals Fortune 100 companies, RxBenefits negotiates competitive, volume-based rates and rebates for companies of all sizes, and provides transparent, client-aligned terms and ongoing stewardship.
  • Utilization Management: A full-time staff of licensed clinicians utilizes a proprietary data platform to ensure the medical necessity, appropriateness, and effectiveness of medications, helping clients achieve optimal clinical and financial outcomes. This includes using predictive analytics and forecast modeling to identify cost-effective alternatives for high-cost, low clinical value prescriptions, and personalized, in-house prior authorization reviews. The PBO model ensures strategies are tailored to the plan’s utilization data and are in the best interest of both self-insured businesses and their members.
  • Experience Management: Unlike a coalition, RxBenefits’ transactional platform provides real-time access to claims and eligibility data so that we can service members at the point-of-sale. This allows us to deliver an unparalleled high touch approach, handling all aspects of plan negotiation, contracting and implementation, plan management, reporting, telephone support, and more, providing a personal approach to the member experience.

With the PBO model, RxBenefits has already saved self-funded employers an average of 26% the first year through contract savings alone, and another 3%-7% through clinical programs. RxBenefits also saves employers money through its annual pharmacy benefits contracts that average near an 11% pricing improvement year-over-year compared to 2%-3% on a traditional three-year contract.

“Several options exist in the market for self-funded employers to carve out their pharmacy benefits and obtain lower costs, but most are one dimensional. A great discount is not worth much if it’s the wrong drug, and passing up competitive rates and rebates is never a good idea. We can no longer afford to let patients fall through the cracks,” said Mark Campbell, PharmD, Vice President of Clinical Services for RxBenefits. “There is a key difference with the PBO model. By leveraging data modeling combined with clinical oversight of pharmacy claims, we are able to effectively serve the best interests of consultants, employers, and patients. Plan utilization and clinical management strategies are foundational and proven to be cost-saving and better at protecting members. Add superior service along with market-leading rates, and employers have a dynamic benefit that truly maximizes the clinical value for their members while supporting an affordable and sustainable program. With a PBO, employers can have best in class rebates, service, and advanced clinical programs without sacrificing one for the other.”

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