WHAT IS A PHARMACY BENEFIT MANAGER (PBM)? A PBM is a company or entity that administers a drug benefit program for a payer. A payer in workers compensation is an insurance company, third-party administrator, or self-insured employer. A PBM is responsible for contacting a retail pharmacy network and a mail-order facility, script processing, paying prescription drug claims, and compliance with state reporting requirements.

CHOSE A PBM THAT MATCHES UP WITH WHAT YOUR COMPANY NEEDS: If your company mainly deals with Catastrophic Claims, your needs will differ from those of a company primarily with Medical Only claims. The medications needed will be vastly different, and claim durations will likely be much longer. The PBM must have the clinical resources to match your clinical needs. If a PBM tells you what your company needs instead of first listening to what your company needs, it will not be a good match. A great PBM will adapt what they do around how your business works.

IT IS CRUCIAL TO HAVE A PLAN IN PLACE: Clearly understand what the PBM can and cannot do. You must have a clear understanding of what is considered generic vs brand name medications and a formulary list. Have specific alerts when a compound has been ordered or when a provider dispenses medications in the office. The other critical component is delegating as much as possible to the PBM and getting the work off the adjusters and the nurse case managers.

OPIOIDS AFFECT CLAIM OUTCOMES: When an injured worker is taking opioids, it increases the amount of lost time from work. The longer an injured worker is out of work, the longer the claim duration. There have been many attempts to try and find a replacement for opioids, but there isn’t a one-size-fits-all. It takes a lot of work, and the industry needs to keep trying. Injured workers need a clinically trained professional to assess them and experiment with different ideas. Some injured workers react well to yoga, meditation, acupuncture, or other medications. Progress is made when we keep trying because we can learn what isn’t working.

KNOW WHAT YOUR COMPANY’S DRUG SPEND PER LOST TIME CLAIM PER YEAR IS: If you have 100 lost-time claims, and each claim spends $100.00, your drug spend is $1.00 per claim. When thinking about a potential PBM, it is vital to know the “price per lost-time claim.” Choose a PBM that has invested a lot in analytics because this is essential to pinpoint emerging trends and obtain a set of reports to measure your savings. If the PBM cannot simplify your price per lost-time claim, this is a red flag.

DON’T FOCUS ON PRICE; IT IS A DISTRACTION FROM THE REAL ISSUES:  Focus on what problems you are trying to solve as an organization. Focus on strategic planning and identifying trends. When the real issues are identified and a plan is put in place, the savings are inevitable.