Emerging trends affect PBM industry

Besides an ongoing trend of mergers and acquisitions, other issues are shaping the PBM market, say experts.

BESIDES AN ONGOING TREND of mergers and acquisitions, other issues are shaping the PBM market, say experts.

These trends include:


"These changes include larger cost differences for members among tiers while maintaining low out-of-pocket expenses for members using the lowest tier," Solberg explains.

The first tier historically has included all generics but now often includes generics or brands that target key disease management classes.


Payers are looking to PBMs to help manage specialty drug spend by making sure that patients have access to the right drugs at the right time and for the correct indications while helping to control costs in this very expensive niche area, according to Ruth Ann C. Opdycke, PharmD, MS, president, TPG Healthcare Consulting LLC, Glastonbury, Conn. "The average cost of a 30-day supply for a specialty drug is well over $1,500," Dr. Opdycke says. "Specialty trend is increasing at double the rate of traditional drug spend."


More employers are choosing to offer HSAs and other types of CDHPs as a way to control health premiums. "Employers are looking for tools that help members choose the right plan and identify high-quality, cost-effective treatment options," Solberg says.


Electronic prescribing and the transmission of complementary information such as benefit design parameters, formulary status and utilization management edits to prescribers at the point of care will drastically change today's healthcare paradigm, Solberg says.


Some PBMs and payers are discussing pricing models based on net drug acquisition cost plus a base PBM administrative fee, says Dr. Opdycke.

-Tracey Walker