Which PBM does Melodia Care use?

Pharmacy Benefit Managers often referred to as PBMs, are essentially the market intermediaries for nearly every facet of the Pharmacy Benefits industry. PBMs do most of the work for nearly 80% of American companies, although many believe that pharmaceutical benefits are provided directly by the health insurance company.

Employers, health plans, unions, and other entities contract with PBMs to communicate with drug manufacturers and handle prescription-related complaints. PBMs are the intermediaries between employers, members, drug wholesalers, pharmacies, and pharmaceutical companies, promoting the best health outcomes at the lowest prices. To ensure the success of a benefits plan, optimize expenses and safeguard the health of employees, it is essential to have an effective benefits strategy and to choose the PBM that best suits the requirements of the company. employer.

What exactly do PBMs do?

PBMs have two primary goals: to select pharmacy prescription drug plan options and to help patients achieve better health outcomes by improving their access to relevant medications.

PBMs work with drug manufacturers, distributors, pharmacies, and plan sponsors.

Decrease spending

PBMs negotiate prices with an extensive network of retail or mail-order pharmacies, enabling them to provide patients and employers with greater access to affordable pharmaceuticals across multiple retail chains.

PBMs provide comprehensive clinical programs, such as quantity modifications, step therapy, and pre-authorizations, to help benefit plan administrators ensure appropriate pharmaceutical use, safety precautions, and discount options costs.

PBMs often serve as advisors to employers, providing advice and suggestions on various plan designs, clinical programs, and other topics.

Learn how competitive PBM sourcing could further reduce your pharmacy benefit spend.

Increase access to medicines

PBMs improve patient access to pharmaceuticals by dealing directly with drug manufacturers or wholesalers. PBMs exchange wholesale acquisition cost (WAC) discounts for quantity discounts that they can pass on to their customers. Additionally, they negotiate rates based on compliance initiatives.

PBMs minimize rising prescription costs, ensure pharmaceuticals are dispensed correctly, and deliver the best outcomes for patient health and well-being. By creating an extensive network of retail or mail-order pharmacies, PBMs can provide patients and employers with better access to medicines across multiple retail chains.

It is reasonable to compare the interaction between the PBM, the pharmaceutical manufacturer, and the employer to an arm wrestling match. PBM is in the middle, connecting manufacturer and employer, and is pushed both ways: to negotiate a fair deal for both parties and to minimize prescription drug benefit costs.

How do PBMs and pharmaceutical manufacturers collaborate?

The connection between PBMs and pharmaceutical manufacturers is complicated. There are a variety of financial barriers that make it difficult to negotiate and understand relationships between drug producers and PBMs.

As intermediaries between pharmaceutical companies and patients, PBMs are responsible for setting the cost of a drug and implementing programs to help patients access prescriptions and use the most effective therapies. These programs consist of:

Rebate programs

PBMs negotiate with pharmaceutical companies to determine the level of reimbursement offered for specific drugs; reimbursements are made to PBM. Depending on the contract between PBM and the employer or plan sponsor, PBM will transfer all, part, or no reimbursement.

Insurance cover

A formulary lists generic and brand name drugs covered by a certain plan. PBMs determine the list with the help of physicians and other clinical specialists to include the most effective and cost-effective drugs. Given the number of pharmaceuticals that pass through a PBM, formulary coverage increases the likelihood that a physician will prescribe a drug. Ideally, a pharmaceutical manufacturer wants to make sure their drugs are covered so they can be distributed to people who need them.

Step-by-step programs

Step Therapy programs are prior authorization applicable to conventional and specialty drugs. Before moving on to a more expensive treatment, the program aims to ensure that patients have tried at least one less expensive drug that has been shown to be helpful for a specific condition.

Prior authorization

Prior authorization is a cost-effective feature that helps ensure that prescription drugs are used appropriately. Prior authorizations aim to prevent the prescription or misuse of certain drugs.

PBMs are also responsible for delivering other programs crucial to improving health outcomes, such as reducing waste and promoting adherence, managing expensive and difficult specialty medications, and administering clinical medications.

How exactly do PBMs interact with employers?

Typically, when an employer contracts with a PBM to create and maintain a prescription benefit plan, the term of the agreement is three years. During the first phase of exploration, both parties work together, and in some cases with brokers and industry experts, to build your ideal pharmacy benefit plan by selecting deductibles, co-payments, coinsurance, and clinical programs.

The company relies on PBM to effectively manage its drug benefits and educate employees about their coverage after the plan is developed. PBMs generally provide contact centers to assist members and can answer questions about network pharmacies and copayments for certain prescription drugs. Most PBMs also provide websites or mobile apps that make it easy to access information about eligibility, top-ups, pricing, and coverage regulations.

PBMs are responsible for the following four main components of the contract:

Statement management

Under a pharmacy benefit plan, PBMs are responsible for processing and paying prescription drug claims.

Rebate Reimbursement

As noted above, PBMs negotiate reimbursement plans with pharmaceutical manufacturers. There are many complex repayment program options. However, the PBM is primarily responsible for managing refunds. Depending on the contract between PBM and the employer or plan sponsor, the employer may obtain all, part, or none of the reimbursement amount.

clinical applications

As part of a prescription benefit plan, clinical programs promote the best clinical outcomes for members. PBMs continually review data and monitor drug consumption to determine what adjustments are needed to achieve the ultimate goal of maintaining or improving health benefits while reducing costs.

Clinical programs, such as prior authorization, quantity limits, and step therapy, are used to ensure patients receive the highest quality care in the most appropriate setting.

Drug Utilization Analysis

PBMs play a vital safety role in prescription drug coverage plans. It’s not always a question of money. Drug use review is a vital program that requires an assessment of a drug’s effectiveness, potential risks, possible drug interactions, and other safety issues. Since PBMs manage their pharmacy networks, they can access a patient’s prescription history and notify patients or physicians of potential adverse drug interactions.

Additionally, the PBM establishes criteria that must be met before certain pharmaceutical products can be delivered. Criteria could include confirmation of the diagnosis, the establishment of the presence of a genetic component, verification that the appropriate tests are carried out and the placement of a specialist during treatment. This is all done to ensure that a patient takes the right steps for treatment, does not exceed the required dose, and responds to the medication.

Employers rely heavily on PBMs to provide trends and insights into the success of their plan and ways to improve it. Employers must constantly interact with their PBMs to ensure that their members always receive the best deal at the lowest cost.

MelodiaCare can help you select a Hospice PBM that meets your organization’s needs for up to 25% less than what you’re paying now. Contact our staff immediately to initiate the process of improving your PBM contract.