Standing next to a pharmacy shelf, a pharmacist looks at a box of prescription medication in her hand.

Pharmacy benefit management

Transparent PBMs, driven by cost savings and integrity

If understanding prescription drug costs seems complex, you’re not alone. With contractual complexity, multiple revenue streams, misaligned incentives and more, there’s a lot that stands between drug manufacturers, employee medicine cabinets and your company’s bottom line.

With so much to navigate, it can be hard for business leaders to untangle: What solutions benefit your business and employees the most? How do you know if they’re actually working? And who really has your best interests at heart?

As a health organization grounded in research, care and coverage, we use our deep understanding and experience to set up pharmacy benefit processes, strategies and checkpoints that drive market-leading drug prescription savings, create unparalleled member experiences and (most importantly) improve care. All for our members, all with transparency and integrity.

The prescription drug industry is complex, with pharmaceutical companies, manufacturers, wholesalers, pharmacies and health plan carriers all playing necessary roles in the supply chain. In the middle of it all are pharmacy benefit managers (PBMs), negotiating distribution, access and prices between everyone involved.

Add in contracts, rebates, incentives, interests and more between players – and you can start to see why a pharmacy benefit plan may not always be optimized for the employer. It’s daunting to try and understand drug pricing and pharmacy benefit management. But the less knowledge you have, the more risk there can be.

Carving out pharmacy benefits from medical benefits creates cost

In the face of all this complexity and rising costs, health plan decision-makers are looking for solutions. One approach is to carve out pharmacy benefits from medical benefits. Touted as providing greater control, lower administration fees and higher rebates, carving out pharmacy benefit management can sound attractive. But carving out the management of pharmacy benefits often causes increased costs.

When pharmacy benefits are integrated with medical benefits, costs are better controlled because programs and experience are managed across benefit plans, creating opportunities that can’t be obtained alone. That means the following elements can be more effectively leveraged to drive lower prescription drug pricing and more:

  • Preferred drug list – Prioritizing the most clinically sound and cost-effective drugs (usually generics), with both medical and pharmacy benefits in mind
  • Prior authorization – Gatekeeping to ensure preferred drugs are dispensed in both medical and pharmacy settings
  • Medication therapy management – Helping members manage multiple prescriptions through cross-referrals among medical case managers and pharmacists
  • Savings – Manufacturer coupons and smart optimizing of significant potential discounts
  • Site-of-care – Negotiating the most convenient and affordable places to get provider-administrated drugs and care

Our HealthPartners® RxRevealed Guarantee lays out exactly what we’ll do for your business and employees – honestly and in plain language. It details making pharmacy benefit management less expensive and more effective, without pricing manipulations or conflicts of interest.

And we back up our promises in ways that most traditional PBMs can’t (or won’t). Our processes are independently audited by a third-party and backed by our guarantee with a money offer to you if we don’t provide the transparency and savings we promise.

Here’s a quick glimpse of the benefits of working with our approach:

  • Across the Midwest, HealthPartners risk adjusted pharmacy costs were 20.3% lower than average.
  • In Minnesota, HealthPartners risk adjusted pharmacy costs were 19.1% lower than average.
  • In Wisconsin, HealthPartners risk adjusted pharmacy costs were 23.4% lower than average.
  • We place our customers’ interests before our own – It’s a reflection of our nonprofit roots: Our clients and members come first, not shareholders or anyone else.
  • We pursue the lowest net cost for prescriptions – Simply put, the more generics used, the lower your plan costs, Some plans will offer higher rebates to help counter the cost of expensive brand drugs. But every $1 your plan earns for a rebate can cost you an additional $2-4 in prescription costs. So by chasing high rebates (which encourage the use of more expensive brand drugs), you can find yourself with a plan that drives greater cost.
  • We actively evaluate and manage costs – We’re continually evaluating the market to ensure we’re always directing members to lower cost therapy options and pharmacies first. Plus, when manufacturers make formulation and dosage changes that create opportunities for savings, we follow suit – making sure our members can get the prescriptions they need at the best available price.
  • You receive 100% of the discounts and rebates we receive – Any and all revenue we receive from manufacturer rebates and negotiated discounts we ensure gets returned back to you.
  • You’ll have complete access to your claims and invoice data – This information is created by your business and employees, so we think you have every right to it. We make it easy to get the data you need to track and monitor our performance, recognize successes and discover opportunities for the future.
  • A straightforward administration fee – Our income from your account is always clearly defined, along with how it’s charged. We believe in transparency. If you don’t see something in your contract, it doesn’t exist.
  • No hidden PBM fees – No consulting or consortium fees, no hidden incentive or profit streams from outside PBMs. Since the very beginning, we’ve tightly integrated pharmacy into our health solutions, removing unnecessary influences.
  • No spread pricing – Spread pricing is an all-too-common business practice, where PBMs charge clients more for drugs than what they’ve negotiated to pay pharmacies. It’s a stealthy way some plans and PBMs make extra money off their clients. Instead, what we pay for prescriptions is exactly what you pay – every single time.

Improving health and well-being is at the center of everything we do. So while our approach to pharmacy benefit management has been proven to save money, we’re even more proud of how it positively affects the lives of those we serve. By seeking the right solutions, not the simplest ones, we can generate savings without sacrificing health.

  • Building long-term affordability – By emphasizing the use of lower-priced generics or biosimilars over rebate-driven brand-name drugs, we’re driving a more sustainable, cost-effective approach to prescriptions. For example, prior authorizations quickly examine the possibility of more effective and less expensive treatment options. And site-of-care optimization seeks places to receive the same treatments at more cost-effective (and, many times, more convenient) locations.
  • Increasing the effectiveness of treatments – Medication therapy management and case management strategies proactively look for more efficient treatments, less loaded with unnecessary prescriptions.
  • Improving member service – Having pharmacy benefits integrated with medical benefits means a simpler, better experience for your employees. There’s no need to figure out which drugs are covered by which benefits (medical or pharmacy), just one carrier that takes care of it all with digital shopping and comparison tools, benefit navigators, and all-in-one plan management.

Taken together, it all means that when a member steps up to fill their prescription, they can be confident they’re getting the right drug, for the right price, for the right reason.

Waupaca County’s leadership needed a new solution for their workforce’s pharmacy benefits. Managers were losing time to jammed-up claims, and the increasing use of specialty drugs was threatening to swallow their budget whole. By partnering with us, the county was able to recoup over $240,000 in costs year over year with zero employee claims issues – all due to our low net cost strategy and proven high member satisfaction.