Pbm tools

Search Options. PBM Assessment Tool. Overview The PBM Assessment Tool is drawn from a subset of eValue8, an evidence-based tool that measures and evaluates pharmacy benefits and health plan performance. Join a collective voice for purchaser expectations As more coalitions and their purchaser members use the PBM Assessment Tool, vendors and administrators will spend more time focusing on the quality and performance measures purchasers want and adopt the best in leading-edge improvement and healthcare quality strategies.

Importantly, when PBMs issue their initial audit findings, the report will include specific documentation that pharmacies can submit to reverse the alleged discrepancies. To the extent the pharmacy has additional documentation to submit, pharmacies must ensure they adhere to the deadlines for submitting such documents included in the initial audit findings, or, alternatively, request an extension of time to submit additional documentation.

After a pharmacy submits its appeal, the PBM will issue final audit findings wherein it will either uphold or reverse discrepancies alleged in the initial audit findings. To the extent that there are outstanding discrepancies included in the final audit findings, PBMs will identify the remaining discrepancies and the final outstanding discrepant amount.

Importantly, the final discrepant amount is usually recouped by PBMs by withholding reimbursement from pharmacies going forward until the discrepant amount is settled. In order to further dispute the audit results after final findings have been issued, pharmacies must initiate a formal dispute process. Other tools PBMs use to support the needs of patients, health care providers, and health plan sponsors in the use and management of specialty drugs include: Formulary management Drug access and utilization management Adherence and compliance programs Site of care optimization Clinical outcomes monitoring Limited specialty pharmacy networks Management of the pharmacy and medical benefits Value and outcomes-based payment models.

Future Considerations Scientific advances and innovation in specialty pharmacy will accelerate in the coming years, adding to the arsenal of cures and beneficial treatments for a wide range of conditions.

Express Scripts. October 8, Sept Health Policy Alternatives. Lotvin, A. Specialty medications: Traditional and novel tools can address rising spending on these costly drugs. Health Affairs. Hirsch, B. The impact of specialty pharmaceuticals as drivers of health care costs. February We use cookies on our website to give you the most relevant experience by remembering your preferences and repeat visits. Close Privacy Overview This website uses cookies to improve your experience while you navigate through the website.

To address these challenges, payers rely on pharmacy benefit managers PBMs to manage the use of, and payment for, specialty drugs.

PBMs offer a variety of tools to manage specialty drugs, including the use of specialty pharmacies. In doing so, the quality and continuity of care patients receive is improved, while ensuring that they derive the greatest value from their medications. As such, PBMs are an essential partner to these payers in the health care system. PBM tools that have been used for years in the small-molecule drug categories to control costs are continuing to be successfully leveraged in the specialty drug category.

The continued use of these cost-saving tools will be essential as PBMs and payers work to manage expenses and enable access to these innovative drugs. PBMs employ a number of strategies and tools to support the needs of patients who are prescribed specialty drugs as well as their health care providers while controlling costs for health plans. PBMs have developed key strategies to maintain access to high-quality care while ensuring that money spent on specialty drugs is not wasted.

These strategies include:. Reducing waste and improving adherence: PBMs use drug utilization review DUR to reduce waste such as poly-pharmacy and implement patient adherence programs to help patients stick to their prescription regimens. Both programs improve clinical outcomes, as well as control prescription expenditures.