Top 3 Things You’ll Learn
- How to evaluate employer-sponsored pharmacy benefits plans
- How PBM contract pitfalls impact self-funded employers
- What questions to ask employers to identify their PBM pain points
There are many parts of a pharmacy arrangement that can either save or cost your clients a lot of money – and not all of them are obvious at first sight. When reviewing pharmacy arrangements with your clients or prospects, use a mix of open-ended and targeted questions to zero in on their pain points.
These 20 questions will help you start the conversation:
Client and Member Experience
Variations in the pharmacy marketplace can substantially impact how much your clients and their members are spending on prescription drugs. New drug launches, new regulations, and improvements in pharmacy pricing are just some of the events that occur frequently. If your clients are locked into a three-year contract with the pharmacy benefit manager (PBM), they will have a harder time responding to or realizing any benefits from changes in the market. Similarly, the traditional practice of shifting costs to members has created a significant burden on members and is no longer as impactful as it once was. A sustainable pharmacy strategy requires a more focused, nimble approach to the client and member experience, with greater flexibility and responsiveness to change.
Questions to Ask Your Clients and Prospects:
- How do you feel about your current pharmacy contract?
- How satisfied are your members with the level of service they are getting?
- Are you able to take advantage of marketplace dynamics on a regular basis?
- What services are available to address member and plan concerns and claims processing issues?
- What data are you using to help you evaluate the financial and member impact of plan changes before you make them?
Pharmacy Arrangement
Most pharmacy programs are either carved-in or carved-out of the medical plan. If the carrier for the medical plan holds the contract with the PBM, then your clients are using the carved-in model. This gives the carrier all the power over pharmacy. If your clients hold the contract for the pharmacy benefit, either directly with the PBM or through a third party, then their plan is carved-out of the medical plan. Carved-out pharmacy plans offer more control and visibility for employers and typically result in a better experience overall.
Questions to Ask Your Clients and Prospects:
- What is your long-term strategy to manage ongoing pharmacy spend?
- Can you manage and adjust the pharmacy benefit as a stand-alone entity?
- What visibility do you have into the pricing terms and performance data for your plan?
- How are high-cost specialty drugs affecting your bottom line?
- What are your rights to audit and exit the contract, if necessary?
There are many parts of a pharmacy contract that can either save or cost your clients a lot of money – not all are obvious at first sight.
Contract Oversight
Your clients deserve a properly structured pharmacy benefits contract that addresses their needs and helps them achieve the best financial and clinical outcomes. However, the language used in a pharmacy contract can dramatically affect their plan’s performance. Terms and conditions that seem inconsequential can easily turn into contract pitfalls. Visibility into the pharmacy arrangement is crucial to know if you have a pharmacy contract optimized for your client’s needs and objectives.
Questions to Ask Your Clients and Prospects:
- How do you ensure that pricing maintains competitive in your existing contract?
- Are contract terms guaranteed at the client level or book of business level?
- Is your pharmacy contract fully auditable?
- What type of rebate arrangement do you have?
- How are generic and brand drugs defined in your contract?
Clinical Oversight
Clinical management provides a critical opportunity for you to help your clients reign in spiraling drug trend, often with minimal impact to their members. An effective clinical strategy should be designed to meet their specific savings and access objectives. It should focus on identifying their risk areas and implementing solutions that prevent the plan from paying more than is necessary for their prescription drug benefits.
Questions to Ask Your Clients and Prospects:
- What tools provide you with visibility into your clinical risk areas and clinical program performance?
- How do you demonstrate your return on investment for your current clinical strategy?
- What strategies are in place to promote preferred cost-effective medications?
- How is your plan protected from paying more than is necessary on high-cost prescription claims?
- How do you leverage available manufacturer assistance funds to offset plan and member costs for specialty medications?
Download this checklist to keep it with you when you meet with your self-funded employer clients or prospects.
