The Right Prescription For RX

Throughout the years it fascinates me how much impact the prescription rider has on health plan premiums.  When it comes down to it, the average cost is around 30% of overall claims.  Therefore, any changes an employer makes to their RX plan will allow for a considerable reduction/increase in their cost and significantly impact how much expenditures their employees will incur at the pharmacy.

A little history is worth mentioning.  Since I have been in the field of small group health insurance, I have watched the RX tiers change from 2 tiers – Generic & Brand – to 3 tiers – Generic, Brand & Specialty drugs.  All insurance carriers utilize a Formulary to determine which drugs are covered and, if so, in which tier.  A deductible, considered by some to be a 4th tier, now introduces a new element to the RX benefit where an employee must pay the full cost of the RX until it is met.

Financial assistance provided by the carriers to their members were offered through mail-order pharmacies.  This answered the bell for convenience and the likelihood of paying 2 co-pays instead of 3 for a 90-day supply.  But what has made this gesture difficult to appreciate is the advent of the High Deductible Health Plans.  These plans do not cover prescriptions below the high deductible and, for many, that can equate to thousands of dollars out of pocket before coverage.

Now enter the world of PBM’s (Pharmacy Benefit Managers) and Discount Drug Plans that are abundant in our industry.  Pharmacy Benefit Managers (PBMs) administer prescription drug plans for over 270 million Americans who have health insurance from a variety of sponsors including: commercial health plans, self-insured employer plans, union plans, Medicare Part D plans, Federal and State government employee plans, managed Medicaid plans, and others.

PBMs reduce drug costs by:

  • Offering home delivery of medications and select networks of more affordable pharmacies,
  • Encouraging the use of generics and more affordable brand medications,
  • Negotiating rebates from drug manufacturers and discounts from drugstores,
  • Managing high-cost specialty medications, and
  • Reducing waste and improving adherence.

These are great features of the PBM’s and they have taken root in the Discount RX plans offered to the public.  Most, if not all, rely on the PBM’s to determine the adjudicated rate at the pharmacy which, unfortunately, can – and will – fluctuate daily.  This leads to discord and frustration when you have a promised price listed on your Discount App that is unable to be met when picking up your medication.

Introducing Strategic Employer Planning’s new partnership with Clever RX.  Because they contract directly with the pharmacies instead of the PBM’s – the price is the price when you go to purchase your script.  They have in their network all the major chains (CVS, Walgreens, Walmart, etc.) and they guarantee they will beat most competitors RX costs on a consistent basis.  Some key factors to consider are:

  • 30% of prescriptions never get filled due to high costs
  • 40% of the top ten most prescribed drugs have increased by over 100% in price
  • 70% of people benefit from a Drug Card due to HDHP’s, High Co-pays, Underinsured or Uninsured
  • 80% can be saved and actually come below co-pays on your medical plan*

Please sign up at – be sure to share with friends and family, employees and employers, or people you simply meet at the pharmacy.  There is no greater thrill then to be able to share it forward – especially when it costs you absolutely nothing but a moment of your time to download the app and enter in a prescription for immediate savings!

*The only caveat worthy of mention is that if you decide to utilize the Discount RX Plan you should always take into consideration how this interacts with your medical plan.  Prescriptions filled with this card will not apply towards your deductible and/or out of pocket maximums.  Simply put – it is either your health plan benefit or your RX discount benefit at the time of purchase.