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

URAC accreditation reflects ProCare Rx’s commitment to achieving and maintaining the highest quality, member engagement and experience, and operational standards for PBMs in the industry

ProCare Rx, a leading pharmacy claims processor, has received updated certification from the Centers for Medicare and Medicaid (CMS) 2025 Prescription Drug Event (PDE) data submissions beginning January 1, 2025. Our certification covers both the Traditional Medicare and Medicaid Plans as well as the Program of All-Inclusive Care for the Elderly (PACE) Medicare Part D. As one of the first dual-compliant providers, our customer regulatory reporting will continue to meet both current and new 2025 submission requirements. This program-wide recertification was mandated by CMS, and included significant changes in the PDE File Layout expansion and introduction of new financial and non-financial data fields on the PDE record. Some of the changes applicable to all Part D sponsors include: “ Vaccine Administration Fee or Additional Dispensing Fee ” (This removed reference to Emergency Use Authorization (EUA) status of oral antiviral drugs) “ Drug Status Indicator, ” determines that the National Drug Code (NDC) submitted on the PDE was an applicable drug or non-applicable drug at the time of PDE processing. For PACE claims there are a variety of additional financial/non-financial fields and indicators that must be included in a claim: Estimated Remuneration at POS Amount (ERPOSA) Pharmacy Price Concessions at POS Patient Pay Amount Patient Liability Reduction Due to Other Payer Amount (PLRO) Other TrOOP Amount/Indicator Selected Drug Subsidy Reported Manufacturer Discount Gross Drug Cost Below Out-of-pocket Threshold (GDCB) Gross Drug Cost Above Out-of-pocket Threshold (GDCA) Low Income Cost Sharing Subsidy Amount (LICS) Non-covered Plan Paid Amount (NPP) Originally Prescribed Quantity Part D Model Indicator Medicare Prescription Payment Plan Indicator Kristi Mitchell, ProCare Rx Vice President of Product Management and Implementation stated, “This certification is a testament to our team’s hard work and dedication. The journey to ensuring that we are able to meet the new CMS reporting requirements on behalf of our clients has been incredibly rewarding, and we express our sincere gratitude to all our clients, employees, and everyone in the ProCare Rx family for their continued support. We look forward to achieving many more milestones together in the future!” The 2025 PDE Testing and Certification Protocol for non-PACE Part D sponsors is posted at www.csscoperations.com 

A Pivotal Moment for PBM Accountability

Gainesville, GA – ProCare Rx is excited to announce that Mr. Russell Cerny has joined the company effective March 25, 2024. In his role as Senior Vice President, Mr. Cerny will be responsible for expanding our strategic partnerships with Health Plans, Health Systems, Benefit Consultants, and large Employer groups. Doyle Jensen, Chief Growth Officer said, "Russ has great integrity and a deep understanding of the industry that will help us deliver our direct-source message of customized and cost effective pharmacy benefit solutions that address the needs of our future customers". As a business development professional with over two decades in the industry, Russ understands problem solving from both an operational and account management perspective. This extensive and varied background in providing pharmacy related services enables Russ to focus on cost containment, membership satisfaction, and ultimately, patient well-being for his clients. Mr. Cerny said, “I'm proud to have joined ProCare Rx, an organization committed to routine technological development and enhancement of their own proprietary claims processing system. Our team provides clients with as little or as much control as desired when it comes to administering pharmacy benefits. We'll support a model that meets our clients’ needs and every client is unique and needs a solution built specifically for them.” About ProCare Rx ProCare Rx is a privately held, direct-source pharmacy benefit administrator delivering industry leading cost savings and superior service to health plans, health systems, unions, and many other payer organizations nationwide. If you are interested in learning more about how ProCare Rx can reduce your pharmacy spend and improve your health outcomes, please contact: sales@procarerx.com.

With the new year comes new Rx updates to plan for and keep an eye on.