Self-funded pharmacy plans rarely have just one cost concern. High-cost brands, combination products, specialty medications, and prescriptions that could be handled over the counter can all drive spending in different ways. Solutions exist, but many PBMs rely on formulary strategies that steer patients toward high-rebate drugs, which may not offer the best clinical value or price.
A formulary helps guide coverage and preferred medications, giving members access to appropriate treatments while limiting unnecessary costs. MedBen Rx offers several approaches to address the different drivers of pharmacy spending.
- High-cost brand and combination drugs: A Discretionary Formulary identifies medications with lower-cost therapeutic alternatives.
- Value across medications: A High-Value Formulary prioritizes drugs that balance clinical effectiveness and cost.
- Non-prescription options: An Over-the-Counter Formulary encourages appropriate OTC alternatives.
- Expensive specialty medications: Specialty pharmacy, biosimilars, Patient Assistance Programs, and alternate Rx sourcing help cover the drugs that drive more than half of pharmacy spend.
For a self-funded employer, having options makes it possible to match strategies to the plan’s actual prescription use. Groups facing several sources of expense may benefit from combining approaches. The goal is to support access to effective treatment while reducing total costs for the plan and its members.
To discuss which pharmacy strategies may fit your plan, contact your broker or MedBen Rx Marketing.