| | OCTOBER 2024MANAGEHRMAGAZINE.COM19and welfare benefits and covers the individual plan sponsors including defense costs. · Receive a copy of your PBM contract and have an ERISA attorney and or benefit broker analyze the: o Contract language Rebate arrangement · Annually reprice your pharmacy over your last 12 months vs. other PBMs not limited to the big 3 (CVS Caremark, Express Scripts, Optum). Navitus is a good example. This includes your generics, brand name and specialty pharmacy. · Include a J-code analysis, which looks at non oral drugs filled as medical expenses vs. within the Rx spend. J codes impact your rebates and may cost than the Rx side.What does the Johnson & Johnson Employee Lawsuit Mean for Us? · Independent Prior Authorization with your current PBM may resolve financial alarms. o During the time of Hepatitis C vaccinations ($90k+), I experienced at least one PBM authorizing fills for patients without a reasonable expectation they would ever develop Hepatitis C. The vaccine was worthless on those patients. A blood test determined this. The PBM gained a $40k rebate but they fell short on clinical protocols. · Drug formulary evaluation identifies whether limited value drugs exist on your formulary. o Example - Duexis is Pepcid and Ibuprofen but costs on average $3,087 a month. · Drug sourcing review, which looks at the various drug channels to determine improvements. o An example - sourcing costly specialty therapies found in your plan from Canada. · Other cost avoidance strategies o Clinical protocols for semaglutide injections for obesity vs. diabetes You may choose to cover this drug class known as GLP-1 for morbid obesity or other diseases impacted by obesity. You might disallow it for patients who have lesser amounts of weight to lose through BMI. WHAT DOES THE JOHNSON & JOHNSON EMPLOYEE LAWSUIT MEAN FOR US? Running the health plan as a prudent fiduciary comes into serious question when one drug is 250x higher than the price available to a patient without group coverage walking off the street into a pharmacy
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