Gaining True Transparency With a Pass-Through PBM Model

Texas Association of Counties (TAC) was established to provide a cohesive voice for all counties and their officials. The counties joined together to establish a group health plan and employee benefits program known as the Health and Employee Benefits Pool (HEBP). The TAC HEBP, comprised of 229 groups, each with different benefit structures and complex plan designs, is one of the oldest and largest public sector benefit pools in the nation.

With the complexity of its pharmacy benefits, TAC HEBP maintained its relationship with a traditional pharmacy benefit manager (PBM) for almost 20 years. Due to ever-increased drug costs, TAC HEBP decided to challenge that status quo in a quest to better manage expenses and explore a new approach to pharmacy benefits.

Increasing Contract Transparency

TAC HEBP’s previous PBM contract was riddled with vague language, which allowed its traditional PBM to continually earn more revenue, while TAC HEBP paid higher and higher claims. A thorough review of its contract revealed sharp limitations on access to data and audit rights, unclear or heavily ambiguous definitions and a lack of clarity about drug pricing algorithms and PBM incentives. Having had no experience with a truly transparent, pass-through model, TAC HEBP didn’t realize how much more visibility into drug pricing and savings it could be getting.

With the help of its consultant, TAC HEBP decided to partner with Navitus.

Reducing Costs and Improving Health

Teaming up with Navitus, TAC HEBP implemented several programs to help improve member access to prescription drugs and contain costs for both the plan and its members. These included:

• An expansion of 90-day prescriptions at retail and mail for maintenance medications, which created a larger network of participating pharmacies, providing added convenience for members. In an effort to minimize member disruption, almost all drugs were grandfathered for the first 90 days. In addition, TAC HEBP permanently grandfathered most medications for the treatment of chronic conditions such as cancer, rheumatoid arthritis and multiple sclerosis for members who were already taking them.
• Utilization management programs, such as prior authorization and step therapy, helped ensure members had access to the most clinically-appropriate, safest and most cost-effective medications. Navitus’ lowest-net-cost formulary focused on recommending lower-cost alternative drugs based on clinical guidelines and drug efficacy. TAC HEBP and its consultant continued to review formulary recommendations on a quarterly bass and make decisions on new-to-market drugs.
• A copay assistance program was implemented for certain specialty drugs dispensed through the specialty pharmacy, Lumicera Health Services, Navitus’ wholly owned subsidiary. This program helped manage member expenses for eligible specialty medications while also lowering the plan’s overall cost. Within the first year, TAC HEBP achieved a significant savings of over $3.4 million from implementing the copay assistance program.

By switching to Navitus and applying these cost savings solutions, TAC HEBP experienced a 23% decrease in total net cost in the first year. TAC HEBP also gained the flexibility it needed to customize its plan design and keep drug costs stable and affordable for its members. The added clarity of Navitus’ transformative pass-through PBM model, with visibility down to the claim and invoice level, allowed TAC HEBP to gain insight into where its drug spend was going, and get more out of its pharmacy benefits.

Getting Started

Are you interested in exploring how a truly transparent, pass-through model could lower your plan spend? Contact us at [email protected] to learn more.