2020 // Issue 1

Consultant Connections is a quarterly newsletter, specifically for employee benefit consultants, dedicated to providing details and data needed to help employer clients maintain high-quality care for their plan participants while keeping prescription drug and related health care costs sustainable.

First and foremost, I hope that you, your families, co-workers and friends are staying safe and healthy as we weather the COVID-19 storm that has swept across our communities, nation and globe. Like others, our team at Employers Health has transitioned to a remote work environment. We continue to work diligently to support our clients, their plan participants and their families in terms of ensuring their pharmacy benefit plans are operating efficiently and effectively. We’ll get through this together!

2020 started with lots of momentum from the previous year. Again, we experienced strong growth during the past year, adding 29 new clients and more than $200 million in pharmacy spend to our industry-leading group purchasing program for pharmacy benefits. This strong growth fuels our ability to continue providing exceptional value to our clients within this rapidly consolidating pharmacy industry.

Our collaborative efforts now include more than 215 plan sponsors headquartered in 34 states, providing benefits to over 1 million lives with nearly $1.5 billion in collective spend. This makes us the largest employer-led purchasing coalition in the market. But beyond volume, we are also happy to report that we consistently have the highest levels of loyalty and satisfaction among our clients with our PBM service providers. It’s a testament to the work of our teams – from our clients, their consultants, the PBM and internally at Employers Health – that we’ve been able to achieve these results.

Even during this current situation, our teams are busy negotiating updated pricing for 2021 through our annual market check process and auditing last year’s performance. We continue to adjust our contracts to meet the needs of our clients and the realities of the marketplace, with the ultimate goal of delivering the highest levels of value to our clients. To date, we’ve added more than $60 million in additional drug spend to our program for mid-year 2020 starts. It’s the best mid-year results we’ve ever achieved.

If you haven’t yet, I invite you to learn more about how you and your clients can benefit from the value of group purchasing for pharmacy benefits through Employers Health.

 


Michael Stull, MBA
Chief Strategy Officer

Finding the Right Fit

Three PBM Options to Meet Your Clients’ Unique Needs

Employers are regularly challenged with finding the right balance in offering a benefit plan that offers appropriate access, coverage, service and cost. While these challenges are common among employers, the priority placed on each can differ, leading to a need for choice in PBMs. Like clients, the PBMs also place different priorities on these aspects of their solutions based on the customers they wish to attract. We recognize these varying priorities and are pleased to offer our clients three distinct offerings: CVS Health, OptumRx and EnvisionRx

These agreements offer employers and plan sponsors contracts negotiated and written by our team of attorneys and PBM experts, containing straight forward and market-leading pricing guarantees, diverse network and formulary management options and robust service and performance guarantees. We encourage discussions early and often to ensure we are matching the right solution for you and your client’s priorities.

With our continued growth we are able to add additional team members to support our goal of helping clients achieve better outcomes and better experiences at a better cost. Our clients benefit from custom clinical solutions developed by Employers Health’s team of clinical pharmacists. Over the past four years, the team has discovered multiple opportunities to implement custom clinical solutions ensuring appropriate use and exclusion of high-price, low-value drugs.

In all instances, the Employers Health strategy was a forerunner to changes ultimately made by the PBM, in this case CVS Health. Early adopters benefited from years of savings prior to those employers who did not implement these options. For 2020, the team has identified three new strategies for dry eye, probiotics and expensive dosage forms. These solutions represent the unique value of Employers Health’s contract flexibility and the work of our clinical team.

Employers Health Clinical Strategy Timeline

House Rules

When Brands are Used as Generics

As our team works with claims data, we are seeing a higher incidence of the use of multi-source brand drugs dispensed in lieu of generics with a dispense-as-written (DAW) code of 5. While this practice historically occurred mostly at mail order pharmacies, we are seeing more of it at retail pharmacies. As an example of the range of incidence, consider the three clients below.

These claims show within the data as multi-source brand drugs. The challenge for employers and their consultants is to identify these claims within the data using the DAW field and ensure that the PBM contract states specifically whether these claims are priced and reconciled as brands or generics, including whether or not they are counted in rebate guarantees. For many contracts, DAW 5 claims are considered generic drugs and patients pay the generic copay even though a brand drug was dispensed.

CARRIER NAMETOTAL BRAND RXTOTAL DAW 5 Rx
A1,8675.2%
B1,40910.2%
C1,12314.1%