Q&A Session on Pharmacy Benefits Programs

Pharmacy benefits management programs (PBMs) are very complex, yet one of the most important things you can offer your employees.

OMNIA Partners Barb Sexton, Vice President, Strategic Supplier Relations - Corporate Services, and Valued Pharmacy Services (VPS) Austin Stolzer, VP of Sales sat down to discuss the most important things you should know about how to get the most value out of your pharmacy benefits program.  

Austin joined VPS in June 2018, working directly with one of the largest hospital systems in St. Louis by helping patients find financial assistance through various savings programs. From there, Austin began working directly with the VPS pharmacist team in the operations and management of clinical programs. He then began working with the Account Management and Operations team managing his own book of business. Through the account management role, Austin worked daily with his clients to provide industry insights, strategic analysis based on drug spend and trends, as well as identifying innovative program opportunities to help address rising pharmacy costs. He currently oversees the PBM Program sales for VPS through OMNIA Partners while also managing financial assistance programs for the coalition. Austin’s professional mission is to provide innovative pharmacy and health benefit solutions to our partners and clients. He has continually provided our clients with innovative ideas and practical solutions to PBM industry challenges. 

Let's dive into their conversation.

Barb Sexton:  What is the value of carving out your pharmacy benefit from the carrier?  

Austin Stolzer: Often times groups look to keep their pharmacy carved-in with the carrier due to the simplicity of only working with one vendor for your benefits and your employees only looking at one SPD document. What groups might not know are the many reasons why making the move to carving out your pharmacy has been benefiting plans. The key benefits to carving out are improved contract rates through discounts and guarantees, freedom to select a PBM outside of your carriers preferred PBM relationship, flexibility into your plan design, and improved transparency into you benefits performance. Flexibility and transparency are key components to operating a successful pharmacy benefit. 

Barb Sexton: Can you elaborate on the improved contracts in a carved out pharmacy benefit?  

Austin Stolzer: With the big carriers all having their underlying PBM relationships, when you are carved in you only have 1 option to select for your PBM (UHC/Optum, Aetna/CVS, Cigna/ESI). When you carve out your pharmacy benefit, the PBMs know that they have an opportunity to win business from the others carriers so their carved out contracts become more competitive. When you carve out you are also able to join a coalition to again get improved pricing through the coalitions buying power with the PBMs.  

Barb Sexton: What is your team doing to combat long term stale contracts that can be found in the marketplace? 

Austin Stolzer: The key to a contract not becoming stale is through market checks. A market check is going to allow the downstream clients of the coalition to obtain the value of the contract improvements that occur on an annual basis. Through the coalition, we provide annual market checks to our clients. This allows groups to obtain the value of the increased contract year over year without having to go through an official marketing each year. There are 1 year contracts that are in the market place but the key is that each year you are going to have to go through a full marketing which can be a lot of work on a group. With our 3 year contracts you can avoid a marketing each year but still be assured that you are staying competitive with the industry. 

Barb Sexton: What do you mean by flexibility with your pharmacy benefit? 

Austin Stolzer: When your benefits are all bundled with the carrier you fall into a “cookie cutter” type benefit. This is difficult because not all employer groups are a good fit for bucket plans that have been pre-made. When you carve out, you are able to fit the plan to the employer’s best interest. With the coalition, groups have complete flexibility into their plan design and any additional programs they would like to implement. Our implementation team works for groups months before go live to ensure the pharmacy benefit was set up exactly how the group intended. This allows groups to react to changes in the marketplace as well. For example, when a new medication is coming to market or there is a specific drug class that is making a splash, groups can make the ultimate decision on how they would like to handle these.  

“There has been a shift to groups electing to cover anti-obesity meds. Historically, groups excluded them as the medications available were not generally effective and some had abuse potential. With the release of the GLP1 agonist class (Ozempic, Wegovy, Mounjaro), which are effective in weight loss treatment, we have seen more groups elective to cover. As far as a recommendation, I would recommend coverage, as the alternative is medical benefit coverage for surgeries etc. Additionally, if there is an effective weight loss treatment covered, it will help with other disease states such as hypertension, diabetes, high cholesterol, and cardiovascular incidents." Brett Clark | PharmD

Q: Do all health plans cover GLP1 drugs?

A: Most health plans cover GLP1 drugs for diabetes without any issues. However, coverage for weight management varies by plan.