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Hylant Asks the Tough Questions of Prescription Benefit Managers

By DR. GINNY CRISP, Hylant Consultant

Last week, “60 Minutes” ran a compelling piece on the problem with prescription drug prices and the many players involved in the web of pharma. The segment highlighted a common misconception about prescription benefit managers (PBM): They are always seeking the lowest net cost for their clients.

Many advertise this as their mission in order to stay competitive. However, they are not contractually obligated to do so. Contracts only require PBMs to provide claim administration services, which should include administering the plan design and cost-share structure, and applying the formulary with corresponding drug utilization management, step therapy and prior authorization programs. Most offer additional clinical programs (which may be assessed a separate fee) that may promote lower-cost options for high-cost drugs (e.g., specialty).

Keeping the role of PBMs in mind, it is imperative you are working with a PBM-agnostic broker or pharmacy expert to ensure your best interests are maintained. Hylant’s keys to success include the following activities:

  • PBM contract review (ensures the most transparent terms)
  • Prescription claims audit (monitors the plan design and ensures claims are paid as intended)
  • Comprehensive plan performance (assesses plan spend and provides actionable cost savings opportunities)
  • Plan design (ensures well-validated cost savings strategies are in place with minimal member disruption)
  • PBM market review (provides competitive PBM services in favor of client)

The rising cost of prescription drugs and the advent of new and more costly medications and therapies will continue to bring this subject into the spotlight. For this reason, Hylant has increased its focus on prescription spend and is providing innovative solutions to this ongoing issue.

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