Formularies are drug lists developed by the PBM for use by their clients, and determine what drugs are considered preferred (thus requiring a lower copayment from the plan member) and which drugs may not be covered at all.. Each drug that makes it to the formulary is placed in the appropriate tier. A plan members’ copayments and the plan sponsor’s drug mix is driven by the makeup of the formulary. Typically, all changes to the formulary are reserved by the PBM. Brand name drugs and the rebates that are derived are often times an overriding influence on how the formulary is balanced by some vendors.
Plan sponsors are typically dependent on the PBM for guidance regarding the formulary. Most PBMs expect the plan sponsor to accept that the formulary has been designed with the plan sponsor’s best interest in mind, and that the plan will be operated for the exclusive benefit of the plan member. However, many PBMs will not warrant and represent that to be true when asked to sign an acknowledgement, prior to engagement.
WBC can review and test a formulary for clinical and evidence-based performance. Our clinicians will provide an independent and objective analysis of your current or proposed formulary. Upon completion, you will know whether your PBM has created a formulary that is consistent with an effort to provide member satisfaction with sponsor cost effectiveness, or whether the formulary has been crafted to create rebates at the expense of reduced net cost.