Why this benefit leader switched to a more modern, transparent PBM

With healthcare costs on the rise, pharmaceutical pricing transparency is becoming a common conversation, from the government to the workplace. For benefit managers, responding means looking beyond the most popular pharmacy benefit managers (PBMs) and considering one that offers better, more visible pricing.

Elaine Britt, executive director of HR operations at Rice University, switched her organization from one of the three biggest PBMs, Express Scripts, to Capital Rx at the start of the school's 2024 fiscal year last July. Finding a more transparent model was a main motivator; the previous one was too complex, Britt says. Employees were having a difficult time understanding why they were paying what they were for medication, and some were finding it cheaper just to pay out of pocket through third party pharmacy platforms, she adds.

"When I started to look at claims, costs and how rebates were calculated, I had a very hard time understanding and untangling the complexities around the traditional PBM model," says Britt, noting that this made answering employees' questions difficult.

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Capital Rx offers a centralized platform for self-funded plan sponsors, with modern technology that allows for easy access, quick changes and scalability. According to the company, they have a 100% implementation satisfaction rate and 99.5% rate for client retention. Britt has already seen the benefits of the platform's design.

"They're much more nimble, so if I see a problem, they can fix it that day," she says. "When I had an issue with something with Express Scripts, I had to submit an order and it would be three to four weeks before the programmers could reprogram things.‍‍

And while technology and flexibility are great, the visible cost savings has immediately shown results.

"What we've uncovered so far just in our nine months is that year over year, our costs are down at least 5%," she says. "We implemented GLP-1s in the meantime, so we had several hundred thousand dollars of GLP-1-added costs, and we're still down 5%. That's unheard of in a healthcare market where everything's going up."‍

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Part of this is due to Capital Rx's model of receiving a flat fee regardless of the pharmacy claim cost being submitted, removing any incentive to push high-dollar drugs and therefore helping to control costs, Britt says. Not only is the university getting better prices on generic medications, but it encourages employees to try alternative medications with a lower price tag.

To make prices as transparent as possible, Capital Rx utilizes the National Average Drug Acquisition Cost (NADAC) benchmark and guarantees prices for clients regardless of size. It also prioritizes customer service, and a tech-equipped call center helps benefit leaders and employee members alike. Combining increased affordability, modern technology and a high level of human touch means a better overall healthcare experience for everyone, says Justin Venneri, senior director of communications and content at Capital Rx.

"[Our team is] incentivized to solve people's problems when they call in, no matter how long it takes," he says. "And the cool thing about the technology is it allows a rep to see what happened to a claim in real time. Why did it get rejected? Why was it approved? They can relay this information to the member and [that person's care team] to ensure the right drug is given to the right patient, at the right time, so the best available price can actually occur."

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This is the kind of support that pharmacists don't always have the time to give, or that is hard to attain for people who are simply picking up prescriptions through the pharmacy drive thru or having delivered. Britt notes that she has called Capital Rx's customer service to gain information about an employee's claim, and can then easily relay the information to the employee.

To make the transition to Capital Rx as easy as possible, Rice didn't hold up anything for prior authorization for the first three months and sent multiple reminders to employees about the shift. It took a few months for everyone to adapt, but things are now running smoothly, Britt says.

"With traditional PBMs, employers have a comfort level, but sometimes taking a chance on a benefit that is so important to people, and where you're leaving money on the table, is worth taking because you want better outcomes, you want transparency," she says. "As an HR person, you're tasked with caring for your population. I've talked to a lot of other employers, and they are having a hard time taking that leap. I want to reassure people that it's not a scary prospect, it is something worth doing."

Source: Why this benefit leader switched to a more modern, transparent PBM (benefitnews.com; 4/29)

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