What to look for in a Pharmacy Benefit Consultant

November 21, 2023
Nobody wants to pay more than they should for any product or service. So, when many companies become concerned over pharmacy benefit costs, they may look for a Pharmacy Benefits Consultant or firm who can help them get the best possible pricing. But pricing isn’t the only factor. How do you choose a Pharmacy Benefits Consultant? The following are some things to consider with that decision.

1) Ensure your Pharmacy Benefit Consultant or firm is committed solely to your best interests.

Choose a consultant that operates ethically, without accepting any fees or incentives from any PBM for placing business.

2) Go beyond the spreadsheet.

Inquire whether the consultant/firm explores deeper factors beyond numbers on a page to identify the most suitable PBM for your organization. Merely plugging data into a spreadsheet doesn’t capture the full complexity for a decision like this. It isn’t that easy. Nor is it accurate.

3) Clarify who will handle the work for your organization and their expertise level.

Verify if they possess a comprehensive understanding of the PBM Industry’s dynamics and experience in uncovering financial risks that may not be apparent when a PBM presents a contract to you.

4) Look at Rebates differently.

Choose a consultant/firm that helps you collaborate with a PBM to optimize, not just maximize, rebates. A substantial rebate earned by overutilizing high-cost or Low Clinical Value drugs may not align with your organization’s best interests. Get rebates where appropriate but don’t get misled by high rebate guarantees.

5) Recognize that pricing isn’t the sole determinant of pharmacy benefit cost.

Select a consultant/firm who works with you and your PBM on Formulary design and seeks true lowest net cost while prioritizing clinical outcomes.

6) Focus on effective benefit Design.

Make Sure the consultant/firm you choose is working with your PBM to design the most effective Benefit Design. Ideally, we should want our benefit program to provide the best possible health outcomes for members at the lowest possible cost. Illness and missed work time costs employers’ money.

7) Guard against overutilization.

An effective consultant/firm will work with your PBM to prevent over utilization. Although good pricing is beneficial, excessive buying diminishes its value. As an example, some PBMs might automatically process and ship refills to members who may not need them.

8) Prioritize Member Experience.

Finally, the last factor that should be considered when hiring a Pharmacy Benefit consultant is the Member Experience. Implementing programs that create chaos for the Plan and/or members is not ideal. Plans should want their members to be engaged in their own healthcare, and complex, confusing benefit programs don’t encourage member interest.

A qualified, honest consultant should be focused on each of the above factors. Focusing only on PBM pricing is not enough.

Crystal Clear Rx welcomes questions or conversations around any of the topics covered in this newsletter. Please contact us to further the discussion.