Tuesday, March 17, 2020

Tuesday Tip of the Week: Get Your Contract Definitions in Order

Non-fiduciary PBMs arbitrarily designate certain generic drugs as brand and non-specialty brand drugs as “specialty” medications. Subsequently, they jack up the price substantially and decree that these specialty drugs can be filled only at the parent-company pharmacy.

How can a PBM arbitrarily designate certain drugs as specialty medications you ask? The same way a non-fiduciary PBM might designate a generic drug as brand. It's all about the contract definitions. In every scenario where a plan sponsor has shared their success with reducing pharmacy costs, they've mentioned the contract. The mention is usually very subtle unless of course you have a trained-eye then it sticks out like a sore thumb. Remove opaque definitions from your PBM contract.

Included above is a transparent definition of 'Specialty Drug' and one we use in our Certified Pharmacy Benefits Specialist curriculum.

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