Recognized as one of the Top 10 Pharmacy Management Solution Providers of 2024 by Medhealth Outlook, this article explores the innovative strategies that make US-Rx Care a leader in the field, featuring US-Rx Care President, Renzo Luzzatti.
The Consolidated Appropriations Act of 2021 (CAA) is making major waves in the self-insured employer space, with a core focus on transparency and proper stewardship of employee benefit plans. However, for over a year, the CAA lay relatively dormant, with delays in enforcement and litigation — until Johnson & Johnson (J&J).
The J&J lawsuit represents the first landmark in CAA litigation, with an unprecedented employee class action lawsuit against excessive prescription drug spending. Digging deeper, we find that J&J’s benefits consultant and pharmacy benefits manager (PBM) allegedly served as the primary drivers of these exorbitant pharmacy costs, preventing a fair and open RFP due to rampant conflicts of interest and hidden profits. The J&J suit is only the beginning — we’re already seeing several new lawsuits come to light as employers are now held accountable for the fiduciary non-compliance of their benefits vendors.
The story doesn’t stop there. Not only are companies as a whole on the hook for fiduciary obligations across their plans, but chief officers themselves are now personally held liable as well. CAA enforcement letters, released by the Centers for Medicare & Medicaid Services (CMS) with state-specific provisions, are now calling for thorough compliance investigations and, if necessary, enforcement action on both personal and enterprise levels.
Recent legal action has made one thing clear: the CAA can no longer be ignored. Employers can no longer claim ignorance of CAA requirements if non-compliance is found, even among their benefits vendors and service providers. The question for many employers now is how to ensure fiduciary compliance with existing vendors, especially PBMs that coordinate drug pricing and administration between pharmacies, drug manufacturers, and health plans. Per the CAA, a plan sponsor’s fiduciary duty is to ensure the plan solely acts in the interest of its participants and beneficiaries.
By comparing prescription drug cost trends and employee cost-sharing structures against manufacturer rebates and administrative fees, employers can identify how appropriately plan assets are being managed, as well as any sources of fiduciary non-compliance.
This process, however, is time-consuming and costly, and it grows even more complex when vendors do not embed fiduciary compliance from the start. That’s why more employers are partnering with a fiduciary PBM like US-Rx Care. When you know your PBM is fully compliant you can gain peace of mind that your pharmacy benefit plan is offering the most value to your participants without opening the door to corporate and personal legal action.
For years, pharmacy benefits managers (PBMs) were left alone to oversee every part of a pharmacy benefits plan from behind the scenes. Without close oversight, PBMs manipulate pricing, contract terms, formularies, and pharmacy sourcing to their benefit. Fortunately, with recent changes to pharmacy regulation, PBMs are now under fire to answer for their many conflicts of interest and financial incentives they use to pad their bottom line. As a result, more self-insured employers and brokers are evaluating their contracts for these issues and exploring new options to protect the best interests of their plans.
Traditional PBMs, including the “Big Three”, have long been criticized for severely inflating the costs of prescription drugs and embedding conflicts of interest throughout the entire benefit. Boiling it down, these are the top three challenges we see in the traditional model:
Standing in direct opposition to a traditional PBM is a fiduciary partner — a different type of PBM that is now a requirement for self-insured employers, per the Consolidated Appropriations Act of 2021.1 The fiduciary PBM model represents a fundamental shift in pharmacy benefits administration, shifting the focus from maximizing PBM profits to optimizing client outcomes, both clinically and financially, by:
With a fiduciary partner like US-Rx Care, you can deliver the best of both worlds: richer benefit value at a lower cost. Learn more about how US-Rx Care’s fiduciary PBM solutions can safeguard your organization against predatory PBM practices to reduce pharmacy spend up to 50% or more in the first 12 months.
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Fiduciary pharmacy benefits organization US-Rx Care is proud to announce the addition of GoodRx to its national pharmacy network. GoodRx is one of the nation’s most recognizable providers of “cash discount” prices on prescription medications, used by millions of individuals throughout the U.S. annually. This relationship augments US-Rx Care’s own network pharmacy contracts to access GoodRx discounts in the event that the GoodRx price is better for a given drug on a given day at a particular pharmacy. This helps self-insured employers strengthen overall benefit value and provides the best possible care to their enrollees.
This unique savings opportunity automatically checks the GoodRx “cash price” discounts at the point of dispensing. Instead of searching on their own for additional savings through GoodRx, plan members can simply present their US-Rx Care health benefits card to the pharmacy, which will compare the US-Rx Care network rate with the GoodRx cash price. The member will always pay the lower amount and earn credit towards their deductibles and out-of-pocket maximums with no paperwork or reimbursement forms to submit. Through this integrated approach, US-Rx Care and GoodRx are working side-by-side to deliver the savings and quality of care that employers and enrollees both expect and deserve.
“As a fiduciary PBM, US-Rx Care puts the best interest of employers and their plan enrollees ahead of anything else,” said Renzo Luzzatti, US-Rx Care Founder and President. “By partnering with GoodRx, we continue to deliver on our fiduciary responsibilities by making it simple for employers to avoid conflicts of interest in their pharmacy plans and drive greater value for their plan enrollees.”
US-Rx Care maintains full contractual adherence to fiduciary duties, ensuring employers with self-sponsored health plans reduce wasteful spending and provide needed medical therapies to their plan members at the most affordable cost. Together, US-Rx Care and GoodRx are committed to enhancing price transparency and increasing flexibility for employer-sponsored pharmacy benefits. By eliminating hidden profits and deconflicting the complex processes within pharmacy benefits management, these two organizations now offer a more cost-effective, clinically responsible, and high-value pharmacy benefits solution.
US-Rx Care is a fiduciary pharmacy benefits organization. We grew up in the health plan environment, working for and consulting to multiple Medicare, Medicaid, and commercial health insurers for over thirty years. At US-Rx Care, clients have access to proven pharmacy risk management programs and solutions that have consistently delivered 30%-50% reductions or more in pharmacy benefit spend for at-risk health plan sponsors. We have also assisted multiple plans achieve dramatic increases in HEDIS / Stars quality scores despite ever increasing thresholds to achieve a 5 star rating.
Building a high-value benefits plan is crucial for self-insured employers to control costs while improving employee satisfaction. However, this is easier said than done on the pharmacy side of healthcare benefits, as prescription drug costs continue to rise in response to a myriad of factors, including inflationary pressures, utilization, and, most notably, the conflicted PBM relationship characterized by hidden profits at the expense of plan sponsors and enrollees.1
Employers who self-sponsor their health plans take a front seat in their pharmacy benefit plan decisions, but selecting the right solution can be challenging due to binding contract terms and a lack of transparency from PBMs. That’s why clinical pharmacy organizations like US-Rx Care provide more than one option, allowing employers to choose the solution that best fits their needs while providing the highest value possible — whether it’s full pharmacy benefits management or behind-the-scenes utilization management.
Selecting the right pharmacy benefits solution depends on a number of factors, including existing vendor relationships, financial considerations, and overall goals for your pharmacy plan. Self-insured employers can select one of these two solutions:
Despite best appearances, a PBM or utilization management organization will fail to provide optimal savings if they do not contractually adhere to fiduciary responsibilities — the same standards that self-insured employers are required to follow. A fiduciary partner like US-Rx Care can fundamentally transform an employer’s pharmacy benefit plan, leveraging a PBM or utilization management solution to unlock higher value and deliver maximum savings for both the plan and its enrollees.
The core difference between traditional and fiduciary PBMs is the ultimate goal of their efforts. Where traditional PBMs notoriously seek opportunities for profit, a fiduciary only works in the plan’s best interest, operating with full price transparency and eliminating every conflict of interest. By removing hidden profits from the equation, fiduciaries can negotiate lower prices, optimize formularies to only include the appropriate medications, and implement cost-saving strategies tailored to each employer’s plan needs.
As a leader in the fiduciary PBM space, US-Rx Care has the clinical and pharmacy benefit administration expertise necessary to sharply cut the costs of needed prescription drugs. Our full PBM solution is proven to save up to 50% on pharmacy benefit costs in just 12 months for self-insured employers. Alternatively, employers who wish to keep their PBMs can carve out utilization management and prior authorization functions to our clinically-based Right Rx program. By advocating strictly for your enrollee’s best interest, Right Rx saves an average of $15-$25 per enrollee per month with over 30% or greater out-of-pocket savings for non-specialty, specialty, and J-code prescription drugs. Whether your organization is looking for partial or full pharmacy optimization, US-Rx Care has the tools and cost-saving frameworks in place to deliver the savings and plan value your enrollees deserve.
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Diabetes remains a leading chronic condition impacting over 38 million people in the United States — over 11% of the population.1 Due to a myriad of lifestyle, environmental, and genetic factors, the prevalence rate is expected to continue its upward spiral, with more than one million new cases per year through 2030. As the healthcare spotlight continues to shine on diabetes management, self-insured employers will grow increasingly responsible for bearing the financial burden of this complex, chronic, and costly condition.
While the current prevalence rate is substantial, we can expect numbers to skyrocket in coming years, as one in three Americans are prediabetic and likely to develop type 2 diabetes, in conjunction with other life-threatening diseases such as heart disease and stroke.2 Only 1.7 million out of the 38 million diabetics have type 1, signaling the primary role of obesity in the onset of diabetes.1 Looking at current statistics for obesity, we can predict a corresponding increase in the number of diabetes cases if obesity is left untreated:
With the growing number of individuals who need medical management for diabetes, new treatments have quickly emerged to manage blood sugar more effectively and help patients achieve an improved state of health — with the added benefit of significant weight loss.
Insulin is the long-standing treatment for an estimated 27% of diabetics, most of whom have type 1.6 However, type 2 diabetics often need additional or alternative treatment. The standard medication therapy typically starts with Metformin, along with diet and exercise modifications. If Metformin alone at optimal dosing is ineffective, Sulfonylureas (Glipizide) or Thiazolidinedione (Pioglitazone) may be added to the treatment protocol. The goal is to reduce Hemoglobin A1c (HbA1c) levels, a standardized metric for blood sugar levels, to below the diabetic range (6.4% and above).
If these initial therapies are in place for at least three months and fail to lower HbA1c below 6.4%, patients can begin taking glucagon-like peptide-1 receptor (GLP-1) agonists, such as Ozempic, Wegovy, or Mounjaro. GLP-1s are used to treat both type 2 diabetes and obesity by slowing the movement of food from the stomach to the small intestine, which reduces appetite and feelings of hunger. GLP-1s can be used with the maximum dose of Metformin when a patient is obese with type 2 diabetes. However, despite its proven efficacy in treating diabetes and obesity, not all GLP-1s are as effective as others and can cause serious side effects, including gastric stasis, pancreatitis, and, in rare cases, thyroid cancer.7
Despite the potentially dangerous side effects, GLP-1s have exploded in utilization in recent years, beginning with off-label use for weight loss and now through the FDA-approved Wegovy dosage designed for treating obesity. However, because generic versions of GLP-1s have yet to be approved, manufacturers and pharmacy benefit managers (PBMs) are taking full advantage of the opportunity to boost their margins for these popular brand-name medications.
GLP-1 manufacturers typically offer “Class of Trade” financial incentives, instead of rebates, to PBMs to ensure placement on the PBM’s formulary and to incent the dispensing of GLP-1s from the PBM’s mail-order pharmacy. These class of trade incentives have resulted in minimal clinical oversight required by the PBMs to approve the use of GLP-1s. In most cases, PBMs will give their stamp of approval if there is evidence of past or current treatment with Metformin — without investigating whether HbA1c levels indicate the existence of type 2 diabetes.
PBMs have struck gold with GLP-1s, as the combination of class of trade financial incentives with the highly sought-after weight loss effects has exponentially increased utilization and sales, with projections of over $71 billion by 2032, according to J.P. Morgan.8 However, by placing profit over outcomes, PBMs are to blame for the continual escalation of GLP-1 utilization and prices — without close consideration of if/how these medications will truly impact clinical outcomes.
Working in direct opposition to traditional PBMs, a fiduciary utilization management partner operates only in the best interests of the plan sponsor and its enrollees. By focusing on medical necessity and clinical rigor, a fiduciary clinical services program like US-Rx Care’s Right Rx service can generate substantial cost savings without compromising patient outcomes. Compared to the current “open floodgate” PBM model, proper GLP-1 utilization management should lead to a 50% cost reduction that enhances the value and integrity of self-insured pharmacy benefit plans.
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