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

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.

Coupon card platforms like GoodRx and Blink Health have made significant inroads with consumers, and a growing number of health care brands are experimenting with direct-to-consumer sales platforms, bypassing insurance benefits entirely. But despite ongoing experimentation with benefit design, consumer-focused savings programs and a lingering PBM rebate rule – which would require individual drug rebate amounts to be passed directly to consumers at the pharmacy counter, currently slated for implementation on 1 January 2023 – the traditional PBM model remains largely intact