Recognizing the Private Market’s Ability to Meet Evolving Demand

Pharmacy Benefit Companies Innovate to Provide Choice for Clients, Lower Costs for Patients

Even as Congress considers more government intervention and “drug pricing” legislation that ironically may prove only to increase prescription drug costs, pharmacy benefit companies continue to evolve to answer the market’s call for innovation by implementing new options for employers providing pharmacy benefits and finding ways to limit out-of-pocket expenses for patients.

The pharmacy benefit marketplace has always been robustly competitive, featuring more than 70 companies that offer a wide array of different programs for delivering savings, reporting information to employers and clients, and numerous types of clinical programs to serve patients and enrollees. Those different offerings continue to grow.

A recent announcement by one pharmacy benefit company is a clear example of the private sector’s ability to develop new programs in response to the evolving needs of patients and employers: As some employers seek more information to design and choose how to manage their drug benefits, the program unveiled last week provides a new type of fully transparent model, including offering additional transparency in traditional or “spread pricing” contracting. This is just one of numerous examples of programs innovated by pharmacy benefit companies that increase transparency and provide an even broader range of choice and optionality for employers when it comes to prescription drug benefit design and coverage.

These new offerings are also meeting the evolving needs of patients, equipping them with new tools that provide drug pricing and coverage information that can be used to help ensure lower out-of-pocket costs.

For example, a new pharmacy benefit company tool, also announced this year, compares available direct-to-consumer pricing for generic drugs with insurance pricing to ensure enrollees get the lowest prescription drug price. Importantly, the program addresses a direct market demand regarding spending in the deductible phase of a benefit. The prices incurred through the program count toward a patient’s deductible and out-of-pocket maximum.

Another pharmacy benefit company is offering an array of services in the Medicare prescription drug program (Part D) that give beneficiaries pertinent information and, in some cases, direct outreach with the end goal of saving patients on out-of-pocket costs. For example, this pharmacy benefit company contacts patient beneficiaries if they’ve filled a more expensive prescription when a less expensive option is available. The company’s Medicare prescription drug offerings also provide a monthly in-depth summary that includes an overview of a patient’s spending. This program allows a patient to review prescriptions, understand the various phases of their prescription drug plan, and talk with their doctors and pharmacists about the healthcare services they receive and the medications they take.

Also, in the Medicare prescription drug program, another pharmacy benefit company conducts focus groups and proactively reaches out to enrolled patients to determine if home delivery or mail-service pharmacy will be a convenient, more affordable option.

The same pharmacy benefit company offers the option of point-of-sale rebates in high deductible plans – a much talked about issue in Congress –and makes recommendations to health plan sponsors offering high-deductible health plans to adopt a preventive drug list, which enables plans to have zero-dollar copays for drugs that prevent disease, regardless of whether patients have met their deductible.

In addition, another pharmacy benefit company uses exclusive clinical predictive modeling and applies it to medical and pharmacy data, making it easy to quickly locate high-cost members and offer opportunities to lower costs.

These examples are just the tip of the iceberg when it comes to innovation in pharmacy benefits. Congress and others in the market are seeking to better understand how pharmacy benefit companies work to lower costs. Policymakers, employers, and patients should all be confident that value is being delivered, that they have the information they need, and that the private market system is working and improving. Pharmacy benefit companies are delivering and should be allowed to deliver without the government dictating the terms in ways that only serve to limit choice and make it harder to manage costs.