WHAT IS A PHARMACY BENEFIT MANAGER (PBM)?  A PBM is a company or entity that administers the drug benefit program for a payer. A payer in worker’s compensation is an insurance company, third-party administrator, or self-insured employer. A PBM is responsible for contacting with 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 be different than a company that primarily has Medical Only claims.  The medications needed will be vastly different, and claim durations will likely be a lot longer. It is important that the PBM has 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:  Have a clear understanding of what the PBM can, and cannot do.  It is imperative that you have a clear-cut understanding of what is considered generic vs brand name medications, and to have 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 to delegate as much as you can to the PBM and get 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 you are thinking about a potential PBM, it is vital to know what is 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 what your price per lost-time claim will be, 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.