While many insurance plans won’t renew until the new calendar year, mid-year is a good time to start thinking about the renewal process and preparing for when it’s time to renew. Even if you’re staying with the same pharmacy benefits manager, consultant, or broker for health benefits, there are some key questions to ask before renewing.

What are my options for a pharmacy benefits manager?

If you’re working with a broker or other consultant on your healthcare benefits as a whole, be sure to ask about your options for choosing a pharmacy benefits manager. Some people don’t realize they have a choice when it comes to their PBM because it’s simply been a line item on their renewal each year, and they may be paying more than necessary because of it. Prescription medications are a significant portion of your total healthcare spend, so be sure to ask about finding the right PBM for you.

What can we learn from our data?

As a self-insured company, you’ve already taken steps toward better understanding your healthcare costs and working proactively to reduce them. By reviewing your data each year, you can better position your pharmacy benefits for the future. Ask your PBM for quarterly data reports plus any insights they can offer based on those reports.

Your plan usage data can help you understand where your money goes and help ensure your plan is the right fit for your employees’ healthcare needs.

  • How many generic prescriptions were filled?
  • How many non-generic prescriptions were filled?
  • Was your plan exposed to any higher-cost, low clinical value combination drugs?
  • Does your PBM routinely monitor new-to-market, high-cost medications with low clinical value and provide your members with lower-cost, equally effective alternatives?
  • What is your current specialty percentage of overall utilization and spend?
  • How is your current year’s plan spend tracking compared to what you expected?

Are there any hidden revenue streams in the existing plan?

How much does your current PBM make to manage your plan, and how is their revenue generated? You may be reading this and thinking, “No one’s going to give me an honest answer to that question!” But, if you’re working with a truly transparent PBM, they will. At MaxCare, we’ll show our customers the complete contracts we have with drug manufacturers and pharmacies so that our customers fully understand their healthcare costs when it comes to prescription medications.

If you ask your current PBM direct questions about revenue generation, rebate levels, or true rebate impact on your overall drug spend and don’t get a direct answer, your plan and your members are probably paying too much.

What are some ways we can reduce costs while still taking care of employees?

When a plan provider can reduce total drug cost, it also reduces the cost to the member. Designing the right pharmacy benefits plan is all about balance and flexibility. As the plan provider, you want to save money where possible on your healthcare costs, but you also want to ensure you’re meeting the healthcare needs of your employees. Does your current PBM offer an in-house managed coupon assistance program? Coupon programs can lower plan cost significantly while often eliminating member cost.

There are lots of different options for designing and administering your plan to help find that balance while offering flexibility. Some of those options include alternative sourcing of high-cost specialty medications, using a reference price program, and maintaining a constant focus on current and new-to-market, high-cost combination medications when lower-cost equally effective options exist.

Is the current PBM truly managing and minimizing our overall pharmacy cost with zero incentive from undisclosed revenue generation?

Your PBM should be a partner helping you achieve the overall lowest pharmacy cost while providing the most successful treatment for your members. If you’re considering a change in your PBM for the next plan year, reach out to us to learn more about the MaxCare difference.