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New PBM Models Aim To Lower Out-Of-Pocket Costs

 
• By Ben Comer

Start-up pharmacy benefit managers such as Capital Rx and Evio hope to shake up the traditional PBM service model with increased drug price transparency, aggregated real-world data and outcomes-based contracting. The big three PBMs which dominate the market represent a formidable challenge.

health care costs
• Source: Alamy

Better price transparency and high-tech analyses of pharmacy benefit manager (PBM)beneficiary data as methods for lowering drug costs are a common refrain among PBMs large and small; Optum, UnitedHealth Group’s $100bn pharmacy services business, for example, has been promoting the concept of analyzing patient data and claims information to lower drug costs for nearly a decade. However, shifts in benefit structures, from high-deductible health plans and co-insurance payments to narrow drug formularies and integrated drug and medical benefits, have led US consumers, who pay more out of pocket than anyone else (see Exhibit 1) to search for new ways to lower costs.

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