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Key PBM Concerns for Health Plan Purchasers Identified in National Alliance Guideline


Sep 7, 2023

The National Alliance of Healthcare Purchaser Coalitions has released a comprehensive guide to help employers and plan sponsors navigate their relationships with pharmacy benefit managers (PBMs). The guide, called “A Playbook for Employers – Addressing Pharmacy Benefit Management Misalignment,” aims to foster alignment and improve negotiations between plan sponsors and PBMs in a complex healthcare system. The goal is to provide employers with the tools they need to make informed decisions about their pharmacy benefit and ensure that PBMs do not have an unfair advantage in negotiations.

The role of PBMs has evolved over time. Initially, PBMs were intended to help control drug spending by receiving rebates from manufacturers and passing them on to employers or insurers. However, there has been a lack of transparency around rebate pass-through in recent years, and PBMs have been criticized for complicating the system and increasing their own profits. The existing business model is flawed and does not deliver high value for purchasers or patients.

The playbook addresses various concerns identified by an advisory committee of industry stakeholders. These concerns include PBMs promoting higher priced drugs over lower priced alternatives, favoring brand-name drugs over generic or biosimilar options, and covering specialty drugs for situations not supported by clinical evidence.

To assist purchasers in their dealings with PBMs, the playbook provides resources such as best practice checklists, sample questionnaires for choosing consultants, and recommendations for contracting language. One key focus is on understanding the economics of the PBM landscape, including the impact of rebates on total drug costs and how rebates can drive formulary decisions and trend.

Overall, the playbook aims to provide employers and plan sponsors with the knowledge and tools they need to navigate their relationships with PBMs and make decisions that prioritize the best interests of their employees and families. By increasing transparency and promoting better practices, the goal is to improve the value and effectiveness of pharmacy benefit management.

By Editor

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