Pharmacy Benefit Manager Comparison of Drug Alternative Use

With the increasing growth of prescription price information from pharmacy benefit managers (PBMs) reaching consumers and prescribing physicians through their Electronic Health Records (EHRs) or member portals, Benmedica has evaluated the completeness of the data provided to consumers with particular attention to drug alternatives. 

Benmedica has evaluated the PBM provided drug alternatives for seven mid-to-large-sized PBMs. We presumed that the information available to members is the same as that which is offered to prescribers via real-time benefit transactions.

*Note that since this article was published, we have been informed by multiple sources that the drug alternatives provided for web portals do not necessarily coincide with those used for real-time benefit check. Member portals may perform better than the real-time benefit drug alternatives.

Our analysis has shown that all the evaluated PBMs have the capability to provide drug alternatives information to providers within their EHRs.

By ensuring that doctors can access actionable information on lower-cost, clinically appropriate alternatives, PBMs can help providers and patients find preferred drugs and drive down drug costs for all stakeholders.

High quality, complete information yields a better experience for physicians and patients, enabling them to make the most-informed prescription decisions. Formulary data in the EHR has traditionally been the source of payer drug information like formulary status, tiers, copays, restrictions, and preferred alternatives. 

Historically, physicians have described bad experiences with the formulary and benefit data in their EHRs due to inaccurate or incomplete data. This perception has lingered, reducing acceptance of formulary information in EHRs, even after some PBMs improved data quality.

Despite PBM efforts to improve formulary data quality, consistency and accuracy across payers continues to be an industry issue.

Even with emerging tools for drug pricing, formulary and benefit (F&B) information is still the most complete and accessible source of information available to physicians through their EHRs since nearly all EHRs support formulary and benefit. When PBMs ensure that their formulary information is complete and actionable, physicians can access information vital to choosing the best drugs for their patients, viewing lower-cost alternatives, and, ultimately, saving all stakeholders time and money.

One of our findings is that drug coverage within member portals is inconsistent and spotty. While most selected drugs displayed coverage, pricing was not always returned and drug alternative information was missing more than 50% of the time.

Some payers who underinvested in F&B have touted the benefits of real-time benefit as a replacement for F&B. But, if what we saw in member portals is consistent with the data in real-time benefit, then this appears to be yet another area of underinvestment where the PBM has simply “checked-off” the real-time benefit support box but hasn’t invested the necessary resources to help doctors and patients make the best medication decisions. 

Consumer prescription cost information, as part of PBM websites and integrated into physician EHRs (as real-time benefit) at the time of prescribing, is a tool that can help patients understand their benefits and reduce drug costs when implemented well. As a complement to F&B data, which supplies physician guidance, prescription cost information provides patient-specific coverage and price information. This partnership helps the provider select the optimal drug the first time which reduces both message fatigue and rework. 

Why Providing Drug Alternatives is Important

Providing alternatives to a prescribed medication gives PBMs a tool to guide patients and physicians to less expensive options. This results in savings for patients as well as payers when preferred alternatives are selected over costlier options. 

Saving time is another benefit. Without alternatives, consumers and physicians must guess at what options, if any, might be less expensive. For physicians, helping patients efficiently during a visit and understanding the patient’s ability to pay their portion of the cost is vital for drug selection and adherence to therapies. For patients, knowing what drugs are covered, restricted, or not covered saves time at the pharmacy and boosts adherence. The need for better cost and alternative information is driving the growth of consumer apps with links to patient drug costs.

In this study, we’ve evaluated the availability and usefulness of drug alternatives information provided by seven major PBMs. We believe that by understanding current information deficiencies and gaps, PBMs will enhance their alternatives data and help doctors make the best prescribing choices for their patients.


Evaluating Alternatives for Major PBMs

As part of this study, the Benmedica team reviewed alternatives across major PBMs using patient portals. We have assumed that cost and benefit information provided by Real-Time Pharmacy Benefit information to EHRs and in patient portals are similar because they are both driven from claims systems. 

Supplemental information like alternatives is a bit more complicated to provide because such data doesn’t reside in a claims system. Developing alternatives requires more knowledge than is available in a typical claims system or even a drug compendia database.

In our evaluation, we looked at several benefit types across seven major PBMs. We examined 25 drugs that were potentially expensive and often not on the formulary to identify what alternatives information was provided to consumers. We also compared the information provided in these electronic systems to any formularies provided on PBM websites. 

 

There were significant variances both from one PBM to another and across therapeutic areas within a PBM. Here we’ll detail some of the variability we found. 

Lack of Alternatives Information

The most frequently found deficiency in our review of alternatives was the lack of any alternatives. Our target list of drugs was rich in alternative options. Frequently, higher-priced medications with lower-cost options had no drug alternatives presented.

Many non-preferred/not covered drugs had no alternatives. Several PBMs provide a list of non-preferred medications on their websites which includes preferred alternatives. In comparing this list of alternatives to the information provided to consumers, we found that the consumer website contained none of these alternatives in many cases. In fact, several of the PBMs included a message stating to the consumer that there are no alternatives available.

Non-preferred and non-covered drugs should logically show alternatives so that physicians and patients can easily identify available treatments. Medicines that are flagged as step therapy or non-preferred/not covered did not always show alternatives in the analysis. Step therapy drugs should have alternatives so physicians can identify the needed prerequisites or prescribe other alternatives that do not have any restrictions.

Providing accurate and up to date formulary information to e-prescribers is the most important thing a PBM formulary manager does. Providing accurate and well-organized formulary alternatives for e-prescribers is even more important. If you are relying on the EHR to provide alternatives, expect to be disappointed.
Ned Hanson, former Senior Director of Formulary Management at Health Net

More Expensive Alternatives

We also found situations where the presented alternative was more expensive than the selected drug. In other situations, not covered drugs were presented as alternatives with no pricing available. Alternatives should be guiding users to lower-cost medications for the patient.

Other cases occurred where generic products, like fluoxetine CPDR 90mg, fluoxetine 20mg tablet, and fenoprofen calcium 400mg, have less expensive generic alternatives. In our analysis, three of seven major PBMs offered no alternatives for these more costly generics. This, again, is not guiding users to lower-cost options.

Being able to view alternatives to higher-cost drugs benefits patients, prescribers, pharmacists and payers by saving both time and money. Unfortunately, it appears that there are gaps in providing this important information at the point of care and in consumer-facing data.
Liz Shea Wilbanks, Chief Clinical Officer at Benmedica.

Restrictive Drug Classifications

From our experience with drug database compendia, we know that some PBMs in our analysis developed alternatives using the drug compendia classifications. Challenges with using compendia classifications to identify alternatives include providing either no alternatives or too many (and possibly inappropriate) options. 

For example, Pradaxa® is the only drug in its therapeutic class and therefore, no alternatives would be shown if Pradaxa was non-preferred/not covered using drug compendia classifications alone. In another therapeutic class, Inflammatory Bowel Agents, the therapeutic alternatives are not all appropriate alternatives for each other.

Real-Time Pharmacy Benefit

Several PBMs provided multiple strengths of the same drug as alternatives, unnecessarily increasing the number of alternatives for review. Real-time pharmacy benefit for physicians and patient portals uses a specific drug, form, and strength to present results. Drug alternatives should also include one comparable therapeutic drug strength per drug. For example, 5 mg of simvastatin is not therapeutically similar to 40mg of rosuvastatin. 

Providing therapeutically similar dosages allows prescribers to select the drug/strength from the alternatives list rather than having to start over with a new drug selection.

Improving Alternatives: A Win for All Stakeholders

How can you improve your formulary performance and drive better alternatives adoption? The answer is to update your formulary data to include actionable drug alternatives information. By giving doctors access to enhanced information, like lower-cost, therapeutic alternatives, they can make better prescription decisions for their patients.

At Benmedica, we’ve developed an innovative process, SmartAlts™, for providing clinically relevant alternatives, that bypasses cumbersome physician and patient processes for researching alternatives and eliminates the need for callbacks and prescription rewriting. With SmartAlts™, physicians can select the most clinically appropriate medications the first time, increasing patient adherence and improving outcomes.

SmartAlts™ provides more complete benefit information, enabling prescribers and patients to have a fuller picture of patient benefits and coverage restrictions. When physicians understand and prescribe within plan limitations, payers save money by paying for preferred drugs and avoid the administrative burden of helping doctors’ offices find covered drugs. 

With SmartAlts™, physicians can select the most appropriate medications the first time, saving PBMs and patients money, increasing patient adherence, and improving outcomes.

Benmedica’s custom-curated lists of alternatives in SmartAlts™ covers 95% of drugs prescribed
Bruce Wilkinson, founder and CEO of Benmedica

We will dedicate a future post to best practices for drug alternatives. In the interim, contact us to learn more about how we help PBMs and health plans save money by providing enhanced alternatives information to prescribers and patients.