Why the Pharmacy Benefit Represents a Unique Opportunity to Enhance Health Insurance Marketplace Offerings

Published Online: February 10, 2014
Katie Sullivan
Susan Fox, director, business and product development, US Script, Inc, says the prescription benefit provides a unique opportunity to attract, attain, serve, and retain members in exchange insurance plans. For one, the health insurance marketplace (HIM) creates a shift by changing how individuals access and sponsors provide prescription drug benefits—in much the same way as Medicare Part D changed how employers provide retiree prescription drug benefits.

Ms Fox says the HIM is both unique and important to exchange offerings. It is unique in that it offers real-time claim processing and precise claim data, and helps facilitate an increasingly collaborative network. It is important because more than half of Americans take at least 1 prescription per year, prescriptions account more than 10% of medical spending, and the HIM can complement medical procedures as well as reduce medical spend.

“The good news for everyone is that there’ll be a larger covered population,” Fox said. She added that providers and payers will be covering a new population, but they will also be changing how care has been delivered to previously covered populations. “So our business relationships will likely be more close, more intense,” she added.

Other key effects of the Affordable Care Act (ACA) include increasing plan options for employers, providing more options for enrollees as buyers, creating additional risk management needs, and enhancing business models.

Ms Fox pointed out that 36 states have opted to offer federally facilitated marketplaces 2014. However, this is also a trend toward private exchanges. Participants in these private exchanges include employers, other sponsors, and coalitions. They enable an employer to shift to a defined contribution model, shift risk from employer to health plans, and favor “carved-in drug benefit.” Health plans that take on that shift in increased risk will look for ways to manage care, manage costs, and attract/retain plan enrollees.

Ms Fox says that while there is an increased opportunity to leverage the pharmacy benefit, there may be a disruption to PBM-employer relationships.

Additional coverage from the PBMI conference available here: http://bit.ly/1gm7PXj