3 Ways a Pharmacy Benefits Manager Can Help Navigate Complex Claims

A comprehensive pharmacy benefits manager (PBM) can work beyond cost-saving techniques, offering clinical oversight and early intervention in an injured worker’s drug regimen. Their clinical management skills can help optimize a claim’s outcome and offer a higher potential for an injured worker to return to a sense of normalcy.

“A strong PBM and third-party administrator (TPA) partnership will be characterized by prompt communications that support the injured worker’s recovery,” said Carol Franklin, Senior Medical Manager at Safety National. The claims adjuster will have a list of automatic drug approvals and necessary pre-authorizations, allowing them to work quickly with the PBM to get an injured worker the medications they need urgently.”

Here are a few characteristics of a well-rounded PBM partnership.

1. Drug Regimen Review

Catastrophically injured workers may be on a variety of different prescriptions, and some have the potential to counteract with existing medications they are already prescribed. To proactively prevent any harmful interactions, a PBM can review an injured worker’s prescriptions with their pharmacist to ensure there are no contraindications. The PBM can also monitor dosing to ensure that specific medications, like muscle relaxers or opioids, are not prescribed long-term. Careful observation may prevent potential prescription addiction and alert prescribing physicians to offer alternatives for an injured worker’s pain management.

2. Enhanced Communication

The PBM will attempt to get buy-in from the prescribing doctor after a review of an injured worker’s drug regimen. Even if an injured worker’s physician does not agree to collaborate with the PBM, it is their responsibility to try. When the physician is open to collaboration with the PBM, they can devise a plan that is optimal for the injured worker’s health and overall cost savings.

The PBM may find red flags, like high-dose narcotics, in their prescription schedule that may signal a need for access to naloxone due to potential drug overdose. Preventing overdose is critical, so the PBM and prescribing physician, along with the nurse case manager (NCM), may work as a team to develop a weaning schedule to prevent long-term use. This schedule can be used in addition to the state’s recommended drug screens to investigate external drug influences, like THC or fentanyl. The NCM will work with the pharmacy and prescribing physician to make them aware of non-injury-related medications the injured worker is prescribed that could have possible drug interactions with their injury-related medications.

3. Prescription Cost Savings

Once a TPA has an established contract, its PBM will act as a negotiator to reduce costs for most medications. Medicare’s standard for prescription costs usually drives those savings. PBMs will deliver savings by offering a percentage off a drug’s average wholesale price (AWP), which is typically lower than the Medicare standard and set by the drug manufacturer. These savings only apply to generic medications outside of rebates offered on brand-name drugs, but those are rarely dispensed in workers’ compensation. A pharmacy benefits manager has more flexibility in pricing with generics than trade drugs, making them more likely to recommend using a generic equivalent first. In managing an organization’s prescription cost benefits, the PBM’s goal will be to provide the best possible pricing while also reducing the ground-up benefits cost.