Gaining True Transparency With a Pass-Through PBM Model: A Case Study

Posted by Navitus Health Solutions on Feb 18, 2021 6:00:00 AM

Are you getting the most transparent and affordable pharmacy benefit solution? If your pharmacy benefit manager (PBM) is not 100% pass through and transparent, you may experience hidden expenses.

According to a National Employer Survey, over 60% of employers say their prescription drug and medical spend is costly and unsustainable. The majority of these employers noted the lack of drug price transparency as the primary factor contributing to this issue, which is further intensified by the fact that traditional PBMs are highly motivated by rebate revenue.

For one plan, the complexity of its pharmacy benefits kept it with its traditional PBM for almost 20 years, despite its increasing Rx benefit costs.

Challenging the Status Quo

Texas Association of Counties (TAC) established a group health plan and employee benefits program known as the Health and Employee Benefits Pool (HEBP or Pool). With ever-increasing drug costs, TAC HEBP decided to challenge the status quo in a quest to better manage expenses and explore a new approach to pharmacy benefits.

Increasing Contract Transparency

TAC HEBP’s previous PBM contract was riddled with vague language, which allowed its traditional PBM to continually earn more revenue, while TAC HEBP paid higher and higher claims. A thorough review of its contract revealed sharp limitations on access to data and audit rights, unclear or heavily ambiguous definitions and a lack of clarity about drug pricing algorithms and PBM incentives.

Reducing Costs and Improving Health

Teaming up with Navitus, the Pool implemented several programs to help improve member access to prescription drugs and contain costs for both the plan and its members.
  • An expansion of 90-day prescriptions at retail and mail for maintenance medications created a larger network of participating pharmacies, providing added convenience for members
  • Utilization management programs helped ensure members had access to the most clinically appropriate, safest and most cost-effective medications
  • A copay assistance program was implemented for certain specialty drugs
By switching to Navitus and applying these cost savings solutions, TAC HEBP experienced a 23% decrease in total net cost in the first year.

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Topics: Case Studies

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