The Role of Pharmacy Benefit Managers in PACE Pharmacy

In the last few years, pharmacy benefit managers, often referenced as PBMs, have taken on an increasingly prominent role in PACE pharmacy. To fully understand the role of PBMs in PACE pharmacy, first consider the role of pharmacy benefit managers more broadly. The American Pharmacists Association defines a pharmacy benefit manager as a third-party administrator of prescription drug programs, working with companies to maintain or reduce the pharmacy expenditures of plans without sacrificing healthcare outcomes. The role of PBMs in PACE pharmacy is more specific—they support PACE Plans  in navigating the complexities of Medicare Part D plan participants. Working with the  pharmacies, PBMs play three main roles in PACE programs.  

PBMs Facilitate the Management of Rebates for PACE Programs

The cost of pharmaceuticals from all types of pharmacies, from retail stores to long term care, is largely determined by pharmaceutical manufacturers. Cost savings can be obtained through negotiating drug pricing with pharmaceutical companies, as well as manufacturer rebates. While PACE plans could try to negotiate directly with pharmaceutical companies on their own, the associated paperwork and follow-up required can be a significant challenge, , in addition to IT and data processing requirements will cause substantial time investment. That’s where the role of the PBM comes into play. PBMs work to streamline the process and help ensure PACE programs obtain the rebates for which they’re eligible. [Tweet “Pharmacy benefit managers play 3 main roles in #PACEpharmacy”]

PBMs Help Ensure the PACE Program Formulary Is on Target

PBMs also play a significant role in establishing and fine-tuning formularies or Preferred Medication lists for PACE programs. Formularies are continually reviewed to incorporate the most cost-effective and clinically relevant medications. Because they’re well-versed in what pharmaceutical rebates are available, PBMs can advise PACE providers about which clinically appropriate medications can be obtained at the greatest cost savings, without sacrificing outcomes for participants. For example, a PBM can evaluate what medications within a class or for a specific medical indication might be best to incorporate into the PACE program’s drug plan.  

PBMs Provide Reporting and Analytics Related to PACE Program

In addition to helping facilitate rebates and working hands-on with a PACE program’s formulary, PBMs also provide reports and analytics related to pharmacy services. Reports often contain an overwhelming amount of data, and sorting through and analyzing the data requires a significant time investment. Typically, PACE pharmacy providers don’t have someone in-house dedicated to analyzing and using this data to create efficiencies and cost savings. This represents one of the most significant benefits of working with a PBM. In this role, PBMs utilize technology to assess the roster of individuals in the PACE plan in real-time. They can then work with the pharmacy to analyze costs and how effectively rebates and the formulary are performing, allowing PACE programs to make just-in-time adjustments as needed. In addition, PBMs can provide the in-depth data necessary to meet Medicare Part D reporting requirements and help PACE programs adhere to associated regulations. Pharmacy benefit managers provide PACE pharmacies with multiple efficiencies. In the future, those efficiencies may also spread into pharmacy services for Skilled Nursing Facilities, as those centers realize how PBMs can partner with their pharmacy provider to help them optimize outcomes while managing costs. Grane Rx partners with AscellaHealth to provide PACE programs with seamless access to cost-effective pharmacy services. Wondering about other ways we can assist your program? Contact Scott Sosso at Grane Rx by calling (412) 449-0504 to learn more about our Precision Medication Management services and other ways we work to moderate costs. ]]>

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