4 Items to Watch on your Formulary

One of Artemis Health’s most important goals is to help benefits administrators better understand their pharmacy benefits. It’s a complex and sometimes confusing world - some might argue by design - but we have experts on staff to help decode Rx benefits.

As the Chief Clinical Officer at Artemis Health, I help benefits teams get a sense for how best to work with their Pharmacy Benefit Manager, how to identify opportunities to eliminate waste, and how to work with data to tell effective stories about pharmacy spend.

First, let’s take a look at the role your Pharmacy Benefit Manager (PBM) plays in your benefits program. These carriers:

• Ensure eligibility when a member fills a prescription
• Create formulary rules
• Assign copays to be charged by pharmacies
• Pay pharmacies for the balance of claims, then pass that cost onto employer group/insurance
• Review and approve prior authorizations

Essentially, they take on the role of claims processor for pharmacy benefits. But there are a few conflicts that can arise with your PBM. Typically, they can profit from per member per month fees and manufacturer rebates that they don’t have to pass along to you, the client. And they can often have a conflict of interest when it comes to your bottom line versus what’s potentially more profitable for the PBM from a rebate standpoint.

That’s why it’s up to you to stay on top of your Rx benefits, learn how your PBM functions, and be your own advocate to reduce unnecessary prescription spending. Your formulary (list of covered drugs under your plan) is a great place to start. The Artemis Platform can help identify areas where you could be missing out on cost-saving opportunities.

Here’s a sneak peek at some categories of drugs that offer opportunities for savings:

Looking for more insight into your Rx data? Artemis can help.