Empowered Decision-Making: Minimize Member Disruption

The ideal approach to pharmacy benefits management incorporates both specialized expertise and your self-funded employer clients’ pharmacy benefits plan data overtime – not the PBM or health plan carrier’s book of business data. By evaluating your clients’ plan performance using their data, you can use the analysis to develop a detailed recommendation tailored to their actual clinical utilization, balanced with their plan savings and member access goals. The result is a client-aligned pharmacy benefits strategy that gives HR benefits leaders and CFOs the power to choose how to manage their pharmacy benefits program.

This data-driven approach to developing a tailored pharmacy benefit management strategy includes three steps: conducting a retrospective analysis, developing tailored recommendations to address your findings, and forecasting the member impact of any changes. When executed together, you will form a complete pharmacy plan performance evaluation and recommendation for your clients that outlines their risks, opportunities, and the member disruption they can expect. The comprehensive pharmacy analysis you deliver to your clients will help them more effectively make the best, data-driven decisions for their prescription drug plan and their members.

A comprehensive pharmacy analysis gives you the insights you need to gain control over the pharmacy benefits plan and make the most informed decisions to manage your plan costs and minimize member disruption.

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Step 1: Gain Clear Insights with a Retrospective Analysis

A retrospective analysis provides important information about what’s already happened based on pharmacy claims previously submitted. By analyzing the fill dates, drug types, and fulfillment channels in the employer’s pharmacy claims file, you can compare what actually happened to what should have happened, following their current contract. In addition to revealing the prescription drug cost and utilization drivers impacting your clients’ specific pharmacy benefits plan, a retrospective plan performance evaluation should compare their actual plan performance to contract terms, analyze pricing and rebate opportunities, and assess clinical (utilization management) program performance. Finally, with the right expertise and knowledge, you can pinpoint the group’s contract opportunities and clinical risk areas.

Step 2: Develop Actionable, Tailored Recommendations

With their pharmacy benefits plan spend and utilization data analyzed, it is time to formulate recommendations to identify, design, and implement solutions that address any challenges or potential inefficiencies that were discovered. You should then consider what additional recommendations might be necessary to help your clients achieve their pharmacy-related goals going forward. Your action plan should be developed carefully, utilizing pharmacy expertise independent of the pharmacy benefit manager (PBM) or insurance carrier, and contain the best opportunities for benefit plan design and clinical utilization management that can help your clients strike the delicate balance between offering a robust benefit, minimizing member disruption, and achieving cost savings.

Step 3: Forecast Budget and Member Impacts

Next, it’s time to model the benefits cost-savings and member impact of potential changes to your clients’ pharmacy plan. The goal with benefits forecasting is to ensure your clients are completely comfortable knowing they have all of the information needed to make the best decisions for their plan and members. Before advising your clients on any decisions, such as changing the pharmacy benefits plan design or implementing a new clinical program, you want to show your clients that you’ve considered all aspects of the recommended plan of action, including the impact on their costs and their members.

Empowering Your Clients

The value of providing each client with a detailed report and recommended strategies, accompanied by the forecasted savings and potential member impact, cannot be overstated. By understanding each of your clients’ specific risks and opportunities, you can help them avoid costly surprises. When the next high-cost drug hits the market or when a member gets prescribed an expensive medication for off-label purposes, your clients’ pharmacy benefits plan will have the necessary programs in place to address it. All because you had the analytics and expertise to put cost-saving mechanisms in place ahead of time.

Furthermore, when you arm your clients with a comprehensive analysis and let them decide how to effectively manage their plan, you are fulfilling your role as a trusted employee benefit consultant. You are giving your clients control over their pharmacy benefits plan and showing that you can be relied on to serve their best interests. Only then can you help them select the best pharmacy benefits partner and plan options that deliver the best pricing, clinical oversight aligned only with their objectives, and a consistent service experience.

To learn more about how to conduct a comprehensive pharmacy analysis, download our free Definitive Guide to Optimizing Pharmacy Benefits.