PBM Industry Principles
PBMs have distinct business processes that differentiate them in the market, but PBMs also adhere to stringent accreditation standards, the terms of negotiated contracts, and legal requirements. In support of our health plan sponsor clients, we are committed to following the highest standards of excellence in business practices and contracting.
These principles reinforce our intention that our interactions with employers and other health plan sponsors are collaborative, meaningful exchanges designed to benefit patients and enhance access to and affordability of prescription drugs.
Our industry commitment adheres to the following principles:
Affordability with Quality Outcomes
- Negotiating unambiguously with clients all contractual and financial terms, pricing arrangements that achieve client goals, performance monitoring, audit rights, and other tools to improve the affordability of drug coverage and improve patient outcomes.
- Delivering lowest net drug costs.
- Using independent clinical experts to develop formulary, clinical programming,
and medical management recommendations for clients that promote high-quality and cost-effective patient access to clinically appropriate treatments.
- Offering financial guarantees and service level commitments.
- Providing actionable, meaningful, and transparent information about prescription drug costs as outlined in the contract, including how much clients pay for each prescription filled by an enrollee in their plan, enrollees’ drug utilization, and rebates and discounts.
- Helping clients provide actionable, meaningful transparency to patients that help reduce prescription drug costs, including what drugs are covered and on what formulary tier, what pharmacies are in the network, and expected costs for their prescription.
- Describing client-related revenue streams clearly.
- Helping patients and providers understand the client’s formulary, clinical programming, and medical management selections.
- Offering plain-language explanations of patient appeals processes to support timely therapy initiation and clinically appropriate use and adherence.
Connection and Resources
- Where available, offering pharmacy network options that include high quality, credentialed, and value-driven pharmacies, including preferred pharmacy networks, specialty pharmacies, and mail-service pharmacies.
- Where available and selected by the client, describing use of accumulator, maximizer, and/or specialty drug assistance programs.
- Where used, describing use of third parties for the procurement of rebates.