THE FAST FIVE: CHANGE IS GOOD. HOW A MEMBER- AND CLIENT-CENTRIC PBM MANAGES TRANSITION

We’ve all heard the phrase “Change is good!” and we strongly agree with this mantra at EpiphanyRx. We’ve been seeing some employers hesitate to move to a new pharmacy benefit manager (PBM) for fear of the impact on their members. Never fear!  

In this Fast Five, we explore these concerns while sharing what it is really like for employers and their employees to move to a better PBM (like EpiphanyRx) with a supportive and comprehensive transition approach. 

1. When an employer chooses to work with a new PBM, what will their employees experience during the transition regarding their medications?  

First and important to note, most employees (members) won’t experience any noticeable negative changes. In fact, looking closely at the top ten medications by claim volume across our book of business*:  

• 95% of claims are covered in the same way at different PBMs. 
• High-volume, low-cost generics make up a majority (80%+) of prescriptions. 
• Major classes of medications remain similar between PBMs.  

However, we know that drug coverage, specifically the difference between what one PBM covers compared to another PBM (and the impact this may have on members), is often the largest concern for an employer considering making a change.  

As a client- and member-centric organization ourselves, we understand wanting to keep members happy and stable on their course of treatment. In rare cases when there are differences in coverage with the new PBM compared to the previous one, impacted members may need to move to a different drug.  

However, this change can be effectively managed with guidance from the new PBM. We also recommend asking about the PBM’s approach during the sales process. If the PBM does not have a comprehensive and member-focused plan, they may not be the right partner. 

2. Why are there differences in clinical strategies including drug coverage among PBMs? 

Some PBMs are incentivized to push products that provide them with higher rebates from drug manufacturers. Because they keep a portion of those rebates, putting those drugs on the drug list (formulary) is important to their bottom line. 

A 100% pass-through and transparent PBM like EpiphanyRx is focused on the lowest net cost for their clients and members. Therefore, the formulary will include more low-cost generics and biosimilars, as well as less expensive brand options. Rebates are passed through at 100%. Therefore, formulary development focuses on drugs that are clinically appropriate, safe, and cost-effective overall.  

Other low-net-cost strategies which help shape our formulary include:  

• Adding generic substitutes for brand medications 
• Adding biosimilars to the formulary  
• Removing expensive drugs from the formulary (because less expensive options like generics or biosimilars are available)   
• Recognizing “me too” medications that are expensive and add little clinical value 
• Utilization management strategies that encourage use of less expensive medications first 
• Limiting specialty drugs to a 30-day supply to prevent costly waste 

3. How should drug coverage changes be managed?  

PBMs with a client- and member-centric model will analyze the impact prior to implementation (during the proposal and finalist stages of the sales process), again during implementation, and throughout the relationship. 

In our experience, it is also important to dive deeper into what the initial analysis shows. Numbers can be deceiving. For example, an analysis may initially show 20% “disruption”, but looking closer, out of the total percentage: 

• There may be acute medications included, and the course of therapy will be completed before the transition takes place, such as antibiotics. 
• Some medication coverage will be “grandfathered” and therefore, no change is needed. Some examples include: Mental health medications that require close monitoring of adherence and effectiveness Hormone therapies Oncology medications 

This leaves a much smaller percentage of members who may need to transition to another medication. Ongoing changes should be also modeled and managed, like when drugs are added or removed from the formulary.  

A PBM with their clients’ and members’ best interests in mind will work to manage these changes when they transition and on an ongoing basis.  

We believe the following best practices are key:  

• Dedicated work during implementation to ensure alignment with the client’s needs including: Identifying and managing special or complicated member cases Ensuring there are no surprises during go-live for the client or member 
• Clinical pharmacist guidance and support throughout the process  
• Member letters sent prior to the change with sufficient lead time. Letters include: Drug(s) impacted and an alternative Process for moving to the new option Timeframe for when change is needed 
• Member support through clients’ Account Management teams, such as sharing member impact lists and letter(s) that will be sent 
• Client and advisor (consultant or broker) communication prior to the change including: Key formulary updates and reminders Drug(s) affected, coverage updates, and previous coverage 
• Discussions with clients about major changes; for example, removal of brand Humira from the formulary 
• An Exception to Coverage Review process to allow providers to document medical necessity for non-formulary/not covered products 
• Grandfathering options for select medications and circumstances 
• Flexibility around transition durations and options 

For employers still concerned after understanding the impact and communication plan, there may be even more guided support available. For example, EpiphanyRx offers a unique “white glove” concierge service. Our Personalized Transition Program (PMT) conducted by our Clinical Engagement Center (CEC) guides members and their prescriber through every step of the process including the following steps:  

• A clinician will proactively reach out by phone to discuss the change and potential solutions with the member.  
• A clinician will also reach out to the prescriber and request a new prescription to be sent to the pharmacy if needed.  

4. Besides drug coverage differences between their new PBM and their previous one, are there other changes the member might experience? 

Again, most members won’t experience any negative changes. Members will continue using their exact medication or a similar one. Likewise, in most cases, employers will continue using their current pharmacy as well.   

In some cases, the plan may choose a new network design, such as one that guides members to different pharmacies (usually to achieve greater savings). Most PBMs offer the following options for employers: 

• A network “anchored” with one major chain. In most areas, members have close access to several chain pharmacies and using the one across the street is not a difficult transition 
• A network that guides members to one or several chains for their 90-day prescriptions while maintaining broad access to any pharmacy for their 30-day prescriptions
• A mail order pharmacy for their 90-day maintenance medications; for example, Costco Mail Order Pharmacy 
• A specialty pharmacy for members with chronic conditions; for example, Lumicera Health Services 

Your new PBM should conduct an analysis based on the network during implementation. We feel the PBM should implement the following best practices during this step to ensure a smooth transition: 

• Work with any out-of-network pharmacies where members are filling prescriptions to get them credentialed and added to the network 
• Allow members time to move their prescription to an in-network pharmacy 

5. What about the HR and Benefits staff that will have to administer the new plan? Should potential member “disruption” get in the way of making a PBM change? 

Implementing and managing a new plan can present change management challenges for Human Resources (HR) leaders, particularly those transitioning from fully-insured or carve-in situations. Managing member changes starts with managing disruption that HR leaders might face. Whether it’s a new risk management approach or a separate prescription insurance card, plan administrators need to feel confident and equipped.   

EpiphanyRx, for example, has an implementation process designed to both simplify and right-size our approach depending on our clients’ starting point, emphasizing critical factors, and guiding our partners to a successful launch. Moreover, we work closely with our clients’ advisors (consultants and brokers) to ensure that all stakeholders are informed, equipped, and confident in our ability to execute. In a recent example, we were rated overall as excellent in providing support to members for a direct-to-consumer business that puts immense emphasis on service for both their customers and employees. 

Potential member disruption should not get in the way of making a PBM change. In fact, making a PBM change can be critical for employers aiming to provide a more competitive benefit package for their employees, including lowering premiums. Employers should keep the following in mind:  

• Switching to a PBM that provides a low-net-cost approach while passing through 100% of rebates and discounts significantly helps employers meet the financial goals of their organization.
• A new PBM can provide better service. For example, EpiphanyRx offers 24/7 Customer Care and a 99% first call resolution rate. Our specialty pharmacy, Lumicera, boasts an 84 Patient Net Promoter Score (NPS). 

In our experience, we have found that with the right communication approach, members can appreciate the change that a new PBM offers. Very few, if any, complain about better service and less expensive pharmacy benefits with equivalent efficacy.   

Lastly, we encourage employers to think through the repercussions of not making a move. Here’s just one powerful story about a member and her husband who moved to EpiphanyRx and experienced a life-saving difference. View Eddie’s story here.

*Across the Navitus book of business inclusive of the EpiphanyRx division. 

“By changing nothing, nothing changes.” — Tony Robbins.  

We encourage you to reach out to us to learn more about EpiphanyRx and how we will guide you through the transition step-by-step. Contact Jonathan Har-Even, VP of Sales, at [email protected] or request a proposal by emailing [email protected].