Pharmacy Benefit Management Concepts: Oversight and Assistance

To help stakeholders understand the key components of their pharmacy benefit plans, National CooperativeRx has developed a three-part blog series where we explore pharmacy benefit management concepts at a high level and answer frequently asked questions. In the first part of our series, we explored costs and access. In the second part of the series, we delved into the operations and strategies of pharmacy benefit managers (PBMs). In this final part of the series, we will dive into PBM performance and support—answering questions about how PBMs gauge plan effectiveness and provide support to stakeholders.

How Do Pharmacy Benefit Managers Analyze Benefits Plans?

PBMs may make adjustments to benefit plan strategies based on insights from claims data. The claims data they receive from pharmacies includes what prescription drugs were dispensed, quantities, costs, and more. This data is compiled and may be summarized into frequent reports to help them identify trends, assess the effectiveness of medication therapies, and optimize cost management strategies.

PBMs may also check to see if the claims data complies with the contractual obligations within their contracts with insurers, pharmacies, and drug manufacturers. To do so, they may conduct their own audits or request an audit from an independent auditor, double-checking reimbursement rates, rebate payments, formulary placements, etc. Audits may also validate compliance with regulatory requirements and operational standards.

Market checks are another tool PBMs use to evaluate their benefit plans’ performance and competitiveness. Market checks involve periodically comparing the PBMs’ current service offerings, pricing, and performance with other PBMs in the marketplace. This allows them to analyze competitor strengths and weaknesses and identify areas where they can refine their own strategies. They may also be able to leverage market research to negotiate better rates. Additionally, they may develop innovative programs based on understanding new trends in the industry.

Fees and availability vary by PBM for data, reports, audits, and/or market checks.

How Do Pharmacy Benefit Managers Provide Customer Support and Education?

Throughout the benefit year, plan participants may have coverage questions, claim disputes, medication inquiries, etc. On the plan participant and provider levels, PBMs may provide support through web-based portals, mobile devices, and customer care phone lines. In some cases, PBMs provide account managers for employer group questions, plan performance insights, strategic guidance, etc. Support services for employer groups, plan participants, and pharmacies, may help minimize disruptions, promote adherence, and enhance customer satisfaction.

Another way PBMs try to increase participant compliance with their pharmacy benefit plans and adherence to their prescription drug regimens is by providing education. PBMs may offer educational programs or communications about understanding formularies, navigating cost-sharing structures, and more. PBMs may also take steps to educate providers, such as explaining formulary updates, prescribing guidelines, and strategies to optimize prescription drug therapies. This helps providers make informed decisions that align with plan objectives, ensuring that patients receive the most appropriate and cost-effective treatments.

Various channels may be utilized for these initiatives, including webinars, informational flyers, online resources, and workshops.

Conclusion

This three-part blog series has explored the key components of pharmacy benefit management, covering the factors influencing costs and access to prescriptions, the inner workings of PBMs and their strategies, and lastly, plan performance and support. By understanding these elements, stakeholders can further optimize their pharmacy benefits and educate their employees.

It is important to note that the PBM industry is intricate, with many complex nuances. While we have discussed some areas at a high level, there are many others we have not covered that also contribute to the overall complexity of the PBM landscape.

National CooperativeRx is committed to empowering stakeholders with the knowledge they need to make informed decisions about their pharmacy benefit plans. To learn more about how National CooperativeRx fits in the pharmacy benefit industry, contact us here—we are happy to introduce you to a more member-focused and honest approach to pharmacy benefits.

Visit our blog page for more educational information and our drug glossary for definitions regarding pharmacy benefits.