The Value of Pharmacy Benefit Plan Reviews

The pharmacy benefit landscape is anything but static. New drugs regularly enter the market, pricing structures shift, and participant needs evolve, making it easy for plan designs to fall out of sync with current market conditions.

A pharmacy benefit plan review is a valuable opportunity to assess what is working, identify areas for improvement, and ensure benefit strategies remain aligned with financial goals and participant needs.

Benefit Design Assessment

A strong plan design not only controls costs but it encourages responsible utilization and ensures access to necessary medications.

• Copay and Coinsurance: Adjusting cost-shares based on current drug prices can help keep the plan affordable and prevent financial strain.
• Tiering Strategy: Drugs are grouped into tiers (generic, preferred brand, non-preferred brand, specialty) with varying cost-sharing requirements. Reviewing these tiers can help determine whether they effectively encourage the use of lower-cost, clinically appropriate drugs while maintaining access to essential therapies.
• Deductibles & Out-of-Pocket Maximums: Affordability is a key driver of medication adherence. Evaluating these cost thresholds helps determine whether participants can reasonably access necessary treatments.

Formulary Review

The formulary guides prescribing and helps balance clinical effectiveness with cost control.

• Generic Dispensing Rate (GDR): A low GDR may indicate that brand-name drugs are being prescribed when generics are available, potentially driving up costs. This may signal a need for improved formulary alignment, provider engagement, or participant education to encourage more cost-effective alternatives.
• Specialty Drug Use: Analyzing specialty drug spend and utilization can help assess whether formulary placement is effectively steering participants to the most cost-effective options or if an adjustment is necessary.

Clinical Program Evaluation

Clinical programs are levers plan sponsors can pull to strengthen oversight and ensure pharmacy benefits remain clinically appropriate and financially sustainable.

• Current Program Performance: Identifying which management programs are currently in place and clarifying their intended goals can help assess whether these interventions are delivering measurable results, such as increased generic drug use, reduced medication waste, improved adherence, or better prescribing patterns.
• Opportunities for New Programs: Exploring new or underutilized management programs can reveal strategic opportunities to enhance oversight, improve outcomes, and reduce unnecessary spend. Consider program goals, who manages them, and fees.

Financial Performance Analysis

Understanding current spend and anticipating future trends is key to keeping the plan financially sustainable.

• Total Drug Spend: Reviewing ingredient costs, fees, rebates, and discounts can help identify how each area is performing and whether they align with expectations.
• Trend Analysis: Comparing year-over-year changes in utilization, pricing, and participant behavior can help forecast future pharmacy costs and identify areas where intervention may be needed.
• Rebate Guarantees: Reviewing rebate arrangements can help ensure contractual guarantees are being met and appropriate value is being captured for plans.

Plan Participant Experience and Engagement

Evaluating how participants interact with the plan can help improve satisfaction, outcomes, and cost-efficiency.

• Network and Dispensing Channels: Evaluating how participants access their medications (retail, mail order, specialty) can help determine whether networks are delivering convenience and cost-effectiveness.
• Days’ Supply: Opting for 90-day supply options for maintenance medications through retail or mail order may improve adherence, reduce pharmacy visits, and lower dispensing costs.
• Education: Providing clear information on generics, formularies, and digital resources can help participants make informed choices, leading to better health and plan performance.

National CooperativeRx’s Plan Reviews

Conducting a thorough pharmacy benefit review requires time, expertise, and strategic insight. At National CooperativeRx, we believe this process should not be a task plan sponsors or their broker/consultant partners have to navigate alone. Our Account Management Team leads in-depth reviews that translate data into strategy, helping plan sponsors uncover inefficiencies, strengthen clinical oversight, and align benefit designs with long-term goals.

Let National CooperativeRx help ensure your plan designs are efficient and aligned with the goals of your organization. Contact your National CooperativeRx Account Representative when you are ready for a thorough plan review.

*Please note: Timelines for implementing plan changes vary. Changes require advance notice. Deadlines for January 1 plan changes may have already passed. For details, please contact your National CooperativeRx Account Representative.