Is Your PBM Working for You…Or Against You? How to Ask the Right Questions and Spot Red Flags in Pharmacy Benefit Management

ProCare Rx Announces New Executive Appointment and Launch of Technology Division to Drive Innovation and Growth The newly created role is expected to solidify leadership of the core technology infrastructure to both enhance support for current clients as well as developing additional value-added offerings to the marketplace.

Understanding the “Most Favored Nation” Drug Pricing Rule

ProCare Rx Appoints John Drakulich as President of their PBM Business

ProCare Rx’s ProCare PharmacyCare, LLC Earns URAC Accreditation in Specialty Pharmacy

Prescription Drug Reform Gains Momentum: What the New Senate Bill Means for Plan Sponsors

The White House recently launched the Make America Healthy Again Commission to address some of the biggest challenges in U.S. healthcare—including chronic disease, medication reliance, and drug safety. While the full impact remains to be seen, this initiative signals potential shifts in how prescription drugs are evaluated, priced, and prescribed. For plan sponsors, employers, and pharmacy benefits managers (PBMs), the key question is: How can we ensure medication access, affordability, and safety while staying ahead of possible regulatory changes? Reevaluating Medication Reliance One of the Commission’s focus areas is over-reliance on medication and treatments. This could lead to a push for more careful prescribing practices, increased scrutiny of high-cost drugs, and expanded support for alternative treatment methods. PBMs can play a proactive role by ensuring plan designs promote clinically effective, cost-conscious prescribing, including: Encouraging use of generics and biosimilars when available Implementing clinical programs that support appropriate prescribing Providing medication management resources to help members navigate treatment options Increased Attention on Drug Safety & Pricing The Commission also highlights food and drug quality and safety , reinforcing the need for greater transparency in pharmaceutical manufacturing and pricing . This could mean: Tighter regulations on imported medications and supply chain oversight More scrutiny on rebate structures and how drug prices are set A renewed focus on affordability strategies for plan sponsors and consumers For PBMs and health plans, transparent pricing models and clear rebate structures will be key to staying compliant and ensuring members have access to safe, fairly priced medications. Eliminating Conflicts of Interest in Health Research Another priority for the Commission is ensuring federally funded health research is free from conflicts of interest . This could impact how drug effectiveness is studied, how formularies are built, and how treatment guidelines are developed. Employers and health plans should work with PBMs that prioritize: Data-driven formulary management based on independent clinical outcomes Objective drug evaluations to balance cost and effectiveness Transparent partnerships with health providers and pharmaceutical companies What’s Next? The Make America Healthy Again Commission is still in its early stages, but its focus on medication reliance, drug safety, and pharmaceutical pricing should not be ignored. Employers and plan sponsors should be prepared for potential policy changes that could impact pharmacy benefits. By working with PBMs that prioritize clinical integrity, cost control, and member education , organizations can stay ahead of the curve and continue to provide high- quality, affordable healthcare solutions. Would you like to review your pharmacy benefits strategy? Let’s talk. Click the button below to learn more about ProCare Rx's Offering and signup to hear from one of our sales team.

FTC Report Reveals $7.3 Billion in Excessive PBM Revenues—What It Means for Employers and Patients

Where We Were and Where We Are Headed GLP-1 usage increased dramatically in 2024, due in part to its dual role in managing diabetes and producing weight loss. The growing popularity of the GLP-1s provides an indication of the medication’s effectiveness, however, it is less certain how employers view the GLP-1s in terms of providing benefit coverage for these types of medicines. To gain additional insight on how self-funded employers are viewing GLP-1s, we took a look at claims from ProCare Rx self-funded employer clients who had at least 1 member attempting to fill the medication this past year. Here is what we found: Throughout 2024, coverage for the GLP1s medications formulated for the treatment of Diabetes was widespread among self-funded employer groups. We found that only 1 in 10 Groups rejected any claim for medicines in this therapeutic class for the reason “drug not covered”. However, this did not mean the percentage of Groups generating a paid claim was 90%. Through the clinical protocols, step therapies and prior authorization requirements put in place on behalf of the plan sponsor and, in some cases then overwritten by the Plan Sponsor, only 6 out of 10 Groups had a paid claim for a GLP1s in this therapeutic category. However, the tide appears to be turning. In the past 3 months, the number of Groups generating a paid claim for Diabetes formulated GLP1s increased to 8 out of 10 Groups. This indicates that coverage restrictions are decreasing and/or plan sponsor overrides are increasing. Overall, the number of paid claims for GLP-1s formulated to treat Diabetes increased by 25% from Q1 2024 to Q4 2024. Unlike the GLP1s formulated for Diabetes, GLP1s medications formulated for Weight Management continued to have limited benefit coverage among self-funded employer groups. 7 out of 10 Groups rejected any claims for medicines in this therapeutic class for the reason “drug not covered.” In addition, clinical protocols, step therapies and prior authorization requirements administered by us and not overridden by the plan sponsor, lowered the number of Groups with a paid claim 2 out of 10. While the number of Groups paying claims for Weight Management GLP1 claims held steady, the volume of claims nearly doubled, increasing by 86% from Q1 2024 to Q4 2024. As we move forward, your organization needs to be prepared for the GLP-1 storm that continues to build momentum, making “Not Covered/No-Coverage” line, harder and harder to maintain. And, for those Groups that did open up and started to allow coverage for these types of GLPs, you will want to make sure programs are in place to manage the volume growth and help ensure proper utilization. This IS happening. Are YOU prepared? Don’t navigate the GLP-1 waters alone. As a trusted partner, ProCare Rx can help you navigate this storm and protect your organization. To learn more about ProCare Rx’s suite of pharmacy benefit solutions, please visit www.procarerx.com