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

When pharmacy benefit managers and insurance carriers play games with your clients’ pharmacy benefits 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 the self-funded employers you aim to help with a new contract or a renewal. One of the biggest mistakes a benefit advisor can make is to spreadsheet pharmacy arrangements against each other without looking at the contractual provisions that can make the deal look better on paper than it will actually perform.

Benefit advisors looking to flush out vague language and create an apples-to-apples comparison quickly can take important steps to evaluate current and future clients’ pharmacy benefits and find the market factors and potential risk areas before it’s too late. In this blog, I’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 experts and consultants in the industry.

Look out! Common pharmacy benefit contract pitfalls ahead

Every day, it feels like a new contract game is being invented to hide costs from plan sponsors in 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 only on the cost of the pharmacy benefit.

For example, benefit advisors should determine how generic drugs are defined in the contract — and how that will impact the plan’s performance — when evaluating a current or future program for a recommendation. PBMs may create their own definitions, especially common with single-source generics. A contract with clear drug classifications may not have 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 seeing the promised savings.

• 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 market check can give a chief financial officer exactly what they’re looking for to evaluate plans without hidden costs, if there’s wasted spending to be eliminated, and if there’s an opportunity for shifting costs off the plan.

Diving into the fine print to find contract pitfalls requires expert experience with pharmacy benefit managers and claims data. Combining expert financial, clinical, and contract knowledge, a benefit advisor can find the best approach for each unique plan sponsor to meet their goals for members and savings.

The power of the team gets even more potent when claims data and contract terms are shared. With these extra expert eyes on the contract, a benefit 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? You can find out in just ten business days.

Whether working with a new or existing client, checking the available market options and current performance is critical to retaining and growing your business. The market will continue to evolve, and the hide-exclusions-in-the-fine-print games will only get more complex. Ensuring pharmacy plan performance aligns with the market means you can keep your clients and their members happy.

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. With our powerful new Enlighten analytics platform, we’ll compile all the data and essential nuggets of information into an easy-to-understand and highly compelling report in just ten business days. Not only will you see projected savings and plan recommendations, but 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.

In less than 10 days, you will:

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

We’ll help you find the right fit for your client, even if it means they stay with their current plan. You’ll know you’ve done your due diligence and can tell the plan sponsor what’s working well and what’s not. Don’t waste another minute on the antiquated spreadsheet of the past. Embrace a better, brighter future.