Aren’t AWP pricing guarantees protecting me and the cost of my Rx benefit?
The short answer is no. There are many ways to manipulate AWP pricing guarantees.
Isn’t Mail Order always less expensive than retail?
Again, the short answer is no. Depending on the benefit design, Mail Order can actually cost more for you than retail. First, how many copays does your PBM or benefit ask from a member when getting three months’ worth of medication? If only one, you may be paying more at Mail than retail. What if your PBM doesn’t utilize the same cost controls on mail order prescriptions that they on retail prescriptions?
Isn’t a large PBM always going to be less expensive than a smaller PBM?
Possibly. While it’s true that larger PBMs have more negotiating power with pharmacies and manufacturers, you may not be seeing the advantages of the larger PBM unless you have a really good PBM contract.
What is true Transparency when it comes to Pharmacy Benefits?
“Transparency” is one of the most overused terms in the Pharmacy Benefit Industry. If your PBM ever uses the phrase “confidential and proprietary,” it is not being transparent with you.
What are some of the key things I should be looking for in a PBM report?
Areas of concern that are identified, along with an action plan for effecting change.
What are some of the key things I should be looking for in a PBM contract?
- The ability to have a custom formulary
- The ability to use any consultant or auditor of your choice
- Clear definitions of Brand and Generic drugs
- Pricing guarantees with well-defined metrics, penalties and rewards
- The ability to utilize any other vendors of your choice
- The ability to leave the contract after one year if things are not going well
What should I look for in a Pharmacy Benefits Consultant?
A consultant who has years of experience in PBM contracts and expertise in data analysis. That’s because using only data or reports that the PBM provides does not lead to good outcomes. A consultant who operates only in your best interests will have no conflicting sources of revenue, such as being rewarded by a PBM for placing business with it.