As plan sponsors navigate numerous aspects of delivering an affordable, accessible pharmacy benefit for their members, it’s critical to consider a holistic pharmacy network strategy.
What Is a Pharmacy Network?
Pharmacy networks are a group of pharmacies that a specific plan sponsor contracts with to provide medication and care at a discounted price. Networks are set up to help plans and members save money, and can be any size. They can also include large retail shops, small, local mom and pop shops, and everything in between, such as mid-sized regional chains.
In order for pharmacies to be a part of a network, they have to meet certain industry standards that all pharmacy benefit managers (PBM) require, such as member safety, meeting government agency requirements and providing best-in-class patient care. Prospective network pharmacies complete initial credentialing as well as re-credentialing at least every three years. Lastly, once credentialing is complete, the pharmacy has to agree to a contracted dispensing rate that might also be tied to member health outcomes.
The right in- and out-of-network pharmacy mix
Just like physician networks, pharmacy networks are designed to achieve optimal plan and member savings. A well-designed network strategy is more than just a list of in- and out-of-network pharmacies, but rather the right coverage to account for population size, geographic area, clinical goals and utilization patterns.
Optimizing a pharmacy network does not have to mean limiting access. In fact, when going from the broadest network to a preferred network structure, 98% of Express Scripts PBM members are still within 5 miles of a preferred pharmacy, thanks in part to the 65,000 pharmacies in the Express Scripts PBM network – more than McDonalds and Starbucks locations combined.
Here are three key elements plan sponsors may want to consider when thinking about an optimized pharmacy network strategy:
Retail or mail pharmacy access for 90-day supply: Members who have chronic, or long-term, conditions and need to take medication regularly can benefit from the ease of a 90-day supply. It may even result in better health outcomes. Express Scripts PBM data show the average increase in adherence for 90-day fills is 19% higher compared to 30-day fills for conditions like diabetes, high blood pressure and high cholesterol1.
Retail pharmacy structure for 30-day or less supply: When members need to take medications for a short period of time, such as antibiotics, they need quick access to their acute medications from a nearby pharmacy.
- Clinical programs for complex conditions: Preferred quality pharmacy networks as part of value-based programs can help to promote adherence, close gaps in care and mitigate downstream medical events for costly and complex conditions. Additionally, condition-specific pharmacists and clinicians can provide important support to patients in navigating their treatment.
Ensuring a seamless member experience
Once a pharmacy network strategy is in place, communicating any changes or new services to members is critical to ensuring a smooth transition. This can include traditional approaches like letters to homes or personalized emails, but additional resources like prescription transfer assistance, in-store support, and web and mobile tools can provide an enhanced member experience.
A network strategy should be customized to fit the plan sponsor and patient needs. Building the right pharmacy network is a lot like shopping for internet and wireless services: when you bundle the right products together, you save. In an unbundled network, there is a lot of unrecognized value left on the table each year -- real money that plans can reinvest into their health benefit to offer additional features or lower premiums. Instead, a strong, bundled network can yield many benefits to the plan and its member – both financial savings and most importantly, better health outcomes.
1 Express Scripts PBM Book of Business, 2021