Prescription drugs can range anywhere from “just affordable” to “sky high”, and inflation isn’t making anything better. With medication costs growing fast, it’s essential to have a PBM with a proven cost-containment strategy. 

Yet, even pharmacy benefit managers have their own hidden costs. For example, over 90% of PBMs lack their own pharmacy networks and in-house claims processing platforms. This means those services must be outsourced, resulting in even more costs. 

Direct-source PBMs, however, don’t have that problem. With wholly owned systems and in-house claims processing, you eliminate the need to pay yet another fee—everything you need is right there. Not only does this mean lower costs, it also means added transparency. 

Let’s take a look at what makes a direct-source PBM different – and how they can help you.

PBMs

Generally, PBMs serve to manage prescription drug costs for health insurers, employers, and others. They tend to have a heavy impact on determining drug costs for insurers, as they negotiate with pharmacies and drug manufacturers to control drug spending. It goes unsaid that this results in a significant influence in determining pay and shaping patient access to medications.1

If we were to summarize, the role of a pharmacy benefit manager is to:

• Develop formularies of covered medication for health insurers, determining out-of-pocket costs and influencing the types of drugs individuals use
• Directly contract with pharmacies to reimburse drugs dispensed to beneficiaries 
• Negotiate discounts and rebates from drug manufacturers by using their purchasing power1

As mentioned earlier, over 90% of these PBMs do not have their own pharmacy networks or in-house claims processing platforms. This means that their transparency has a limit. When these services are contracted with a third party, a level of transparency is lost and it is guaranteed at least one piece is out of the PBM's hands – and out of sight. 

The Direct-Source Difference 

Direct-source pharmacy benefit managers cut the cost – and risk – of outsourcing. With that, exploring the distinction between direct-source PBMs and regular PBMs is simple. When it comes down to it, ownership defines the difference. Only direct-source pharmacy benefit managers have:

• Wholly owned systems
• Wholly owned pharmacy contracts 
• Transparent rebate structure

The name speaks for itself. A direct-source PBM offers everything you need from one trusted, accessible source. Your system and services are unbiased, privately owned, and independent—all while retaining high quality. Instead of having to rely on one or more third parties to help manage your plans, direct-source PBMs keep everything in one place, from all your capabilities to all your solutions. 

And the benefits of direct-source stretches beyond just that. The clear and transparent business model provides a window into the world of claims and costs, allowing you to trace the path of patient claims. You get direct system access and private label options, so your benefit program remains undoubtedly your own. Instead of losing track of your claims process through the tangled field of outsourcing, our direct-source system allows you to see the full scope of patient claims, ensuring that you can see the full picture, every step of the way. 

As a direct-source, transparent PBM ourselves, MC-Rx, powered by ProCare Rx, knows the value of strong programs and services that are wholly owned. Our technology allows us to account for each and every dollar of drug spend -- something most other PBMs can’t claim. We control our entire process, allowing us to oversee every step and provide you with accurate data and representation. 

Since our founding, we’ve remained committed to our clients’ best interests. With innovative cost-reduction programs for high-cost medications, clinical programs focused on the lowest net costs, and fully transparent pass-through models that provide you with full accountability of spend, our solutions are customized to ensure the greatest level of success.

At MC-Rx, we’re happy to walk you through our processes or answer your questions 24/7/365. 

It pays to partner with a direct-source PBM. Ready to start today? 

References:

https://www.commonwealthfund.org/publications/explainer/2019/apr/pharmacy-benefit-managers-and-their-role-drug-spending