Considering a PBM’s Savings Tool? 10 Questions to Ask Right Now

Pharmacy benefit managers (PBMs) typically offer clients value-added, member-facing tools designed to help members manage prescriptions, make more sense of their pharmacy benefit, and maybe save a few bucks. What else can you ask for?

Quite a bit, actually. If member tools are a factor in your PBM decision, or you’re considering an independent pharmacy benefit solution, ask your team and consultant 10 important questions:

1) How comprehensive are the savings suggestions? 

PBM tools usually show cost-saving options for many common medications. Suggestions are typically brand-to-generic switches, fulfillment changes, and sometimes a clinical alternative or two. The latter may require a little digging by the member. And, historically, PBMs don’t dig too deep into the suggestion well. A member might never see a generic-to-generic opportunity, or a brand combination drug split into two low-cost generics, or any less common but clinically sound option.

2) Is there proactive member outreach? 

Rx Savings Solutions claims analysis shows time and again that a majority of people on maintenance medications have some lower-cost option available on their formulary. Whether it can save them $5 or $500, how would they know if they never found their way to the tool?

3) What are the engagement and outreach touch points?

Member populations are more demographically and technologically diverse than most people realize. If the only way to engage with the tool is through a desktop or mobile app, that may automatically limit access for non-digital natives or “unwired” populations. Ask about alternative engagement points, such as direct mail, SMS/text messaging, and phone access.

4) Is there dedicated member support, and how do members rate it?

Even the best tool and user experience can’t eliminate the confusion in pharmacy benefits. Members will always have questions and problems that only trained experts can resolve. Inquire about contact centers—if they’re separate from the PBM’s primary member services—and ask about things like physical location, average wait times and NPS scores.

5) How are prescription changes handled at the prescriber level?

Clinical alternatives usually represent the most substantial cost savings available from most formularies. Savings can only be captured if the prescriber approves the switch, something many members are reluctant to pursue. Ask if a member can request approval through the tool, or whether the PBM has an established channel for prescriber outreach.

6) How do members find and use the tool?

They shouldn’t have to Google it. However, PBMs may have multiple tools for different purposes. Some may be rebranded or replaced from one year to the next. Desktop access should be in a familiar place, but also ask if there’s a mobile app so users can check out-of-pocket price for a drug their doctor is about to prescribe. Are alternatives shown that they can ask about beforehand? Can a user check different pharmacies’ prices before the script is called in?

7) Is the tool integrated with your plan design and point solutions? 

Ideally, the tool should be accessible through your health plan’s member portal without additional login credentials. Medical and pharmacy plan data integration will paint the most accurate price picture for the member, especially if it accounts for deductible phase. Integration with health benefit solutions puts actionable information in more places and makes for a seamless experience.

8) How are specialty medications handled and presented?

Depending on the specialty medication and the member’s plan design, a member could see whether the drug is covered, subject to prior authorization or step therapy, and maybe the price for a competing brand drug. Often absent are suggested generics for multisource specialty drugs, which can carry the lowest price-tags for the member and the plan.

9) What sort of reporting is included? How do you know if the tool is working?

If the tool is a value-add, chances are there won’t be metrics reported on member engagement, conversion rate, member and plan savings, adherence or other trends. It might be a tough ask for monthly, in-depth reporting from a free service. Still, it’s worth seeing if your members and plan are seizing opportunities or missing them.

10) Which member experience would you prefer?

Finally, ask to give prospective tools a thorough test drive rather than rely on slides or a demo. Put yourself in your members’ shoes. Determine how easy or difficult the user experience would be for the least tech savvy in your population. If you were trying to manage prescriptions and reduce your household bill, would it really help you?

Yes, there’s a lot to ask and factors to evaluate. It’s important research to conduct in today’s benefits landscape. How else do you measure true ROI on a $0 investment?