June 2, 2020

When considering a PBM, self-funded groups should be aware that PBMs are unregulated, and transparency claims are entirely at the discretion or invention of their sales strategy.

With the spotlight focused on high drug prices and the role PBMs play, it is easy to unders...

February 27, 2020

To a mid-sized self-funded health plan $5 million in Rx spend may seem like a lot. However, to a Big 3 PBM, managing 80% of all prescription drug claims, it can be a drop in a bucket. Now image you manage a plan spending less than $1 million? Lost in the crowd, these...

March 19, 2019

Many of you are probably shaking your head no.  It is understandable why. You may not be as comfortably versed in the pharmacy benefit because you already juggle medical, vision, dental, and stop-loss. 

Maybe you don't believe it will make a difference?  However, A...

September 13, 2018

It is worth evaluating the benefit of using a mid-sized PBM for self-funded entities providing pharmacy benefits to 10,000 or fewer

The three largest PBMs, who hold over 80% of the industry market primarily focus on larger life group sizes. For smaller groups under 10,...

August 15, 2018

There are higher profits for processing claims than in collecting premium and absorbing risk.

For every claim that crosses the PBM’s ledger, the PBM gets a portion. There is never a claim that doesn’t make the PBM money whereas the medical carrier only profits from clai...

April 26, 2018

From the onset, drugs are priced by the manufacturer and are influenced by FDA regulations that include exclusivity periods and generic launch delays.  During the exclusivity period, drug manufacturers want to solidify their market position by handing out coupons direc...

April 11, 2018

Retail drug pricing begins with what is called the MAC (Maximum Allowable Cost), this is a ceiling cost on most generic medications. For example, Amoxicillin 500mg, a commonly prescribed antibiotic, typically wouldn’t cost an employer a MAC greater than 50 cents per pi...

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