Trying to work with PBM healthcare plans is like approaching a puzzle with no box and not knowing how the pieces fit together. This can be a problem since business leaders seeking useful healthcare benefits must make informed cost-saving and wise choices about PBMs.
To help you, I have broken down the PBM healthcare plan selection process in plain terms that are simple enough for anyone to understand and make informed decisions. Let’s look at how to choose the right PBM healthcare plan with this step-by-step guide.
A Step-by-Step Guide to Choosing the Right PBM Healthcare Plan
PBMs serve as intermediaries between drug companies, insurers, and pharmacies. Their primary role is handling prescription benefits, from negotiating drug costs to managing the claims process. They also decide what’s covered and how much your staff pays at the pharmacy.
Choosing the right PBM healthcare plan can directly impact your team’s access to affordable medications and your business’s bottom line. With that in mind, here’s a simple, zero-stress, step-by-step guide to help you make the best choice:
Step 1: Understand your workforce needs
Each group of employees is unique. Some groups have higher demands for maintenance medication, whereas others have greater dependency on acute or single-use prescriptions. Analyzing usage patterns informs what features, such as mail-order capabilities or specialty drug assistance, will be most valuable in meeting your employees’ needs.
Read more: Understanding PBM in Healthcare
Step 2: Compare plan options side by side
Once you understand your workforce’s requirements, assess how each PBM meets those needs. Carve-in arrangements can bring simplification in the form of bundling with medical benefits, whereas carve-outs provide greater transparency into drug pricing and service level customization. Don’t take the one-size-fits-all approach for granted.
Step 3: Scrutinize the formulary
Not all formularies in PBM healthcare plans are created equal. There are some that exclude necessary medications or offer high-cost substitutes. Drill down into the list to ensure your employees can access effective, affordable treatments. I recommend you look for a flexible PBM healthcare plan that updates its formulary regularly.
Step 4: Review pricing models
Pricing schemes can either make or break your PBM experience. Spread pricing can have concealed markups that drive costs up unnecessarily. Pass-through models, on the other hand, focus on transparency. You should seek partners who clearly state fees and avoid surprise pricing because transparency will always foster trust.
What Questions Should You Ask a PBM Before Signing a Contract?
PBM selection requires asking the right questions before signing on the dotted line. An effective partner will embrace openness and offer transparent, honest responses. Begin by inquiring about their approach to pricing, rebates, and overall service provision.
Ask them how they price their fees—do they charge based on true drug costs, or are there any markups applied? Ask how often they report performance metrics, whether you’ll have insight into spending patterns and prescription trends, how flexible their drug list is, and if it can be modified based on your workforce demographics.
Also, don’t forget about service. Ask what sort of assistance your employees can expect if they have questions or encounter problems with their prescriptions. Do they provide immediate assistance, or are questions referred through automated systems? These dialogues will provide insight into how responsive and goal-aligned the PBM is with your business objectives.
Read more: Top Skills Every Pharmacy Benefit Manager
Final Thoughts
Picking a PBM healthcare plan is not just another HR task on your list; it’s a choice that affects employee satisfaction, corporate culture, and your company’s bottom line. An appropriately aligned PBM healthcare plan partner enables you to deliver higher-quality care with fewer headaches.
So here’s the thing: If you’ve ever asked yourself what PBM is in healthcare or attempted to break down the PBM meaning in healthcare, the solution is in wise planning accompanied by the proper partnership and understanding, which I hope to have helped with. However, you can look at my LinkedIn if you have more questions.
