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PBM Benefit Insights

When considering a PBM, self-funded insurance plans should be aware that they are unregulated and are not required to disclose deals taking a cut of potential Rx savings.

With the spotlight focused on high drug prices, it is easy to understand the appeal to carve out the Rx benefits to a pass-through model where the PBM will transfer their network discounts, rebates, and general PBM services for one simple administrative fee, typically calculated as Per Member Per Month (PMPM).

When considering a PBM, self-funded insurance plans should be aware that they are unregulated and are not required to disclose deals taking a cut of potential Rx savings.
How Transparent is PBM Pass Through Pricing?

When contracts are passed-thru multiple PBMs and pharmacy benefit resellers, there are hidden revenue streams cut from the spread of each network claim, percentage taken from rebates, and formulary management fees. Potential savings diminish when processed through this funnel.

Retail networks are pre-negotiated and subject to variable and potentially less aggressive discounts at smaller or more poorly negotiated pharmacies. Your PBM may not reliably deliver on promised savings when network discounts are “passed-thru” as they are, with no adjustments.

APC believes a pharmacy benefit plan will achieve goals of optimal savings when they negotiate for a guaranteed AWP discount across the entire network. When a PBM is obligated to deliver on their negotiated AWP discounts, they assume more risk, which subsequently compels them to renegotiate low-performing network contracts actively.

APC breaks you out of the world of restrictive canned PBM contracts. We believe all payers, no matter the size, deserve PBMs who fight for their business. APC works with a network of mid-market PBMs who remain accountable to their guarantees. Our PBM expertise can help craft a contract and plan design that delivers the best savings and outcomes. We offer an alternative to the smoke, mirrors, and the long, costly RFP process to help the payor efficiently underwrite their policy and provide budgeting forecasts. After the contract is signed, APC stays to provide PBM management to ensure the PBM delivers on promised savings.

To a mid-sized 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 imagine you manage a plan, spending less than $1 million? Lost in the crowd, these smaller groups are often missing out on savings and flexibility.

 

APC has over 15 years of experience in PBM procurement and management. As small group advocates, we understand the unique needs and challenges of managing a self-funded healthcare plan. We actively curate a vetted PBM marketplace and can work with your organization and Benefits Consultant to provide efficient PBM acquisition, implementation support, and ongoing monitoring and reporting. An innovative and competitive marketplace of mid-market PBMs offers competitive rates, flexible contract terms, ongoing monitoring and reporting, and implementation support.

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, APC with ten years experience in PBM procurement and analysis, discovered the under 5000 life groups are significantly under-served. With larger insurance brokerage firms forming exclusive deals and coalitions with the same top three PBMs, smaller groups looking for choices are being offered the same product but with different labels.

APC maintains strong relationships with a network of mid-market PBMs that are willing to work hard to win new groups. Through this network, we have been able to offer our Benefit Advisor partners improved customer service, valued relationships, and innovation sparked from actual competition. Then there are the potential savings! On average, mid-market PBMs are charging 35% less than the top three PBMS.

Best part, this improvement comes with minimal disruption! Mid-sized PBMs use the same pharmacy networks and formularies so in most cases implementation is generally no more than just switching out a drug card.

If you are a Benefits Advisor looking for a unique approach for your under 5000 life groups, let an APC Pharmacy Benefit Consultant assess your latest contract or plan review to identify areas of opportunity and cost savings strategies.

APC would like to be your pharmacy partner and connect you to a network of PBMs who will value your business and provide you and your clients a unique approach that will differentiate you from your competition.

Contact us at info@apconsultgroup.com or your APC Pharmacy Benefit Consultant to get started!

 

Learn more about our exclusive PBM marketplace by watching the video below!

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