Choosing a PBM

September 2023
One of the primary services CCRx offers prospective clients is to assist them in the selection of a new pharmacy benefit manager, or PBM. Sometimes we are asked to utilize a Request for Proposal (RFP) process to narrow down the field of choices to the best possible candidates. But is that the best way to select such an important vendor?

PBMs have become quite adept at answering RFPs. Some of the larger organizations have studied PBM responses and they know how to answer these questions in a way that will score the highest with the Plan Sponsor. They know that payers have become skeptical of the rebate process so they incorporate language that they feel will help calm any fears that Plans may have. They promise aggressive AWP discount guarantees. And they’ll even re-price claims using the lowest possible pricing available in order to show prospective clients significant savings over their current vendor.

The problem with the RFP (which we call “Request for Promises”) and the re-pricing process is that many PBMs will not abide by these promises, nor will they use the lowest possible pricing in practice. And there is no governing body regulating their answers to RFPs. As a result, most RFPs and re-pricing exercises are worthless.

Instead of asking PBMs to make promises that we know most will not keep, Crystal Clear Rx utilizes a much more in-depth process to find PBMs that will live up to their promises and that serve our clients well. For the most part, we only consider PBMs that are willing to work with us to eliminate loopholes and contractual issues that are not in our clients best interest. We measure pricing not by the easily and frequently manipulated AWP discount, but by dollars and cents at the unit level. We don’t care too much about the AWP discount as long as our clients pay the least for their drugs in terms of dollars and cents per dose.

The consultant you choose should have no ties to the PBM financially. CCRx does not receive any financial incentives from PBMs in exchange for a recommendation. PBMs are recommended based on their performance.

Pricing is not the only factor CCRx looks at when evaluating PBM performance. We expect our PBM partners to help us ensure that first line therapies are tried before they approve higher cost, secondary medications. This is a critical part of the PBMs job. It requires on-going evaluation due to the fact that new specialty drugs come to the market frequently; and because existing drugs sometimes are found to be effective treatments for conditions other than what they were designed to treat.

We also strive to find PBMs that share our concern for member service. Giving members the tools to help us manage pharmacy costs is another very important consideration. We want our members to be good consumers, and to do so they need tools to help them understand when there are lower cost therapy options available, and which pharmacies offer the lowest pricing. Today there are many new vendors offering solutions that can generate big savings for both the plan and member. But helping the member navigate these many choices can be confusing, and so we need tools that will help us simplify the options, making it easy for members to make better choices.

Finding the best PBMs in the Universe is a full-time job. It requires on-going effort due to new drugs and vendors coming to market, and ever-changing regulatory and other conditions. Using 20+ year old tools and ideas to select a PBM is not the best way to identify the best vendor for such an important benefit. CCRx can help.