May the Fourth Be With You: PBM Rebellion

HR, CFO and CEO Rebels: I have a 4 prong challenge for you today - but it's potentially high reward, with little risk. (Best kind.)

Specialty drugs are eating plans alive in cost these days - typically 1-2% of all prescriptions on a plan are specialty drugs, but they can cost anywhere between 30-85% of a total Rx plan spend for an entire year on cost.

What are specialty drugs, anyway? These are high dollar, high touch, high monitor, often injectable drugs that require special handling. Some might be only from a handful of pharmacies (called limited distribution drugs). Some may have risk programs assigned to them (REMS programs). This is also the bucket where orphan drugs and gene therapies reside. Here's an article I wrote over at Apex's blog on the Universe of Specialty Drugs. The bottom line: they're expensive, and they're not going away any time soon.

If you want to be a true rebel this May 4th and reign in your specialty drug spend, (and get to be a hero with your boss at work by laser focusing on this very expensive area of your plan, potentially) ask your PBM for the following 4 metrics around specialty drugs right now:

4 Questions to Ask Your PBM on Specialty Drugs:

1. How the PBM defines a "specialty drug" - make them articulate to you what their definition is, because everyone's definition is different. Have them show you the definition inside the PBM contract.
2. Have the PBM tell you how many specialty prescriptions they saw in your plan in the last 12 months. One? Three? Thirty? How many - using their definition? What percent are specialty drugs of the total Rx pie?
3. Then, have the PBM tell you how much of the total your plan spent on specialty drugs in the last 12 months. Thirty percent? Fifty percent? More? Tens of thousands, hundreds of thousands, or more? Bonus ask: if your PBM is carved in with your medical plan - ask them for this spend on both sides of the plan (specialty drugs in the MEDICAL benefit, and then specialty drug spend in the PHARMACY benefit.)

***May you not insert the shock here, but if so....****

4. Last - and here's the best part, rebels - ask the PBM specifically what they're doing to curb specialty costs on your plan now. If they don't have any good answers, it's time to find a new PBM.

It's okay to expect more from your PBM. They should know all of this. If they don't - run. It's your company's money - spend it wisely.

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Erin L. Albert is Kinetiq Health Pharmacy Benefits Practice Lead at Apex Benefits, along with a team of Certified Pharmacy Benefits Specialists. Opinions here are her own, based upon hundreds of interactions with 55+ PBMs.