The AffirmedRx Grading System: Check Your PBM Performance

The AffirmedRx team has developed a grading system that will allow you to check your PBM performance to help navigate the industry’s complexities. Protect yourself from profiteering practices by working with PBMs that put people over profits—like AffirmedRx.

When dissecting your PBM contract, you may notice a lack of transparency regarding pricing, policies and more. Traditional PBMs typically use opaque language to curb self-funded employers from receiving the most from their plan; oftentimes, this means the public is paying more for prescriptions while the PBM industry profits.

Grading Scale for PBM Performance

Don’t allow large-scale PBMs to continue their for-profit practices—take a look at your current contract to decipher whether you’re getting the best plan for your money. We’ve outlined an easy-to-use grading scale to optimize your plan according to the most common areas of abuse traditional PBMs tend to practice.

Criteria #1 – Market Placement

80% of the PBM market is controlled by the “Big Three” PBMs. Due to their total jurisdiction over the market, they have no incentive to transition their businesses toward a patient-centric model.

PBM performance in our lens accounts for employer/member satisfaction. Net Promoter Score (NPS) is a great criterion to help determine satisfaction. NPS is a customer-experience metric measuring loyalty while predicting business growth. Scores are calculated by asking an initial survey question on a 0-10 rating scale, then accumulated ratings are set between -100 and 100. The Big Three PBM NPS scores fall on the following negative scale:

  • ExpressScripts: -63
  • CVS Health: -13
  • OptumRx: -3

Endless profiteering practices exploit customers’ lack of knowledge about the pharmaceutical industry—something traditional PBMs incentivize through a lack of transparency. Consumer trust, despite market placement, is a necessary criterion for how you should be rating your PBM.

Criteria #2 – Contract Language

One of the biggest challenges faced by employers is deciphering the intricate language of PBM contracts. Contractual complexities within pharmacy benefits management can obscure the true nature of the services provided, making it difficult for employers to ascertain a plan’s true value and cost. Opaque language may conceal hidden fees, rebate arrangements or other financial intricacies that can significantly impact the overall cost of a pharmacy benefit plan.

Criteria #3 – Patients Over Profits

Understand if your PBM prioritizes Patients over Profits

  1. Evaluate your PBM’s formulary management, ensuring access to a comprehensive range of medications offering the least expensive, most clinically effective options, focusing on generic over brand name.
  2. Check on your PBM’s patient care team. Do they serve as an advocate for your members? See if they offer:
    a. Medication Assistance
    b. Adherence Support
    c. Prior Authorization Support
    d. Medication Synchronization
    e. Benefits Guidance
    f. Financial Assistance
  3. Evaluate whether your PBM offers clarity in their pricing models, fostering transparent communication with employees and members.

Criteria #4 – Data Analytics: Transparency & Access

Do you have access to your data? Transparency and data analytics play a pivotal role in effective pharmacy benefit management. By providing clear insights into prescription drug costs, utilization patterns and formulary management, you can understand whether your benefits plan is optimized.

Additionally, clarity in your data analytics allows for identifying trends, proactive management of costs and enhanced patient outcomes.

Transparency and data-driven insights are the cornerstones of AffirmedRx’s approach, ensuring employers and their members have the knowledge and tools they need to confidently navigate the complex landscape of pharmacy benefits.

Criteria #5 – Technology & Flexibility

Many PBMs function on antiquated, twentieth-century technology, producing ineffective results. This outdated technology is expected to solve high-complexity clinical decision-making, with further complications in rapidly evolving medical evidence and subsequent medical policies.

At AffirmedRx, we meet twenty-first-century challenges with modern, flexible technology that is health-focused and capable of integrating with a myriad of vendor applications, allowing for seamless implementation.

Criteria #6 – Know Your Network: Partnership and Pharmacy

Does your PBM own its supply chain or pharmacy? Do they require you to use their mail order or specialty pharmacy services? Vertical integration in the PBM industry has raised concerns, particularly regarding the ownership and partnership of drug manufacturers and pharmacies by the Big Three PBMs.

PBMs have surrounded themselves with other companies owned by a singular entity. This means that insurers, PBMs, specialty pharmacies and provider services are all owned by one governing company that incentivizes higher costs and opaque policies.

This arrangement poses problems. Drug manufacturer price mark-ups are primarily driven by internal revenue targets and earnings goals rather than by rebates and discount increases paid to PBMs, as the drug industry often asserts. Such integration creates conflicts of interest—such as a PBM deciding what to pay itself when forcing fulfillment through same-entity owned pharmacies—limiting the leveraging power in negotiating lower drug prices. This emphasizes the need for increased transparency and fair pricing practices in the pharmaceutical industry.

Wrapping Up – Questions to Ask Your PBM

Regarding this information, here are some specific questions for your PBM to shed light on their opaque practices:

  • What are you [PBM] doing to drive the lowest net cost for my plan?
    • You want to receive effective care for the lowest cost.
  • Do you work with drug manufacturers to encourage the use of generic medications?
    • Generic medications result in the same effectiveness as brand-name drugs due to their chemical structure, but get to evade the intensive testing that drives up price. If your PBM is working for YOU, then they should be offering generics.
  • How are you ensuring that only the most clinically effective, lowest net-cost drug is preferred for my plan?
    • There should be measures that encourage the use of generics over brand-name medications, opting for a patient-centric model.
  • What are your fee structures and rebate offerings, especially regarding GPO involvement?
    • Be sure to see the rebate and net spend for the last three years to compare whether the GPO helps drive rebates or saves you money.

When it comes to pharmacy benefits, you want to be active in the contract negotiation phase to ensure you’re not being taken advantage of. Too often, our industry has opted for profit to impress shareholders rather than caring for the people they represent.

Total Your Numbers: What Grade Does Your PBM Get?

At AffirmedRx, we put Patients over Profits. We’ve implemented a public benefit corporation designation to ensure that our business practices can focus on our members rather than stakeholders.

To maximize your PBM performance, work with the AffirmedRx team of professionals to optimize your plan based on your needs.

See how AffirmedRx™ can bring clarity, integrity and trust to you and the lives you impact

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