When evaluating the alleged advantages of a bundled medical and pharmacy approach, employers and consultants should ask their medical carrier a few critical questions:
- Does the carrier outsource its prescription drug program to a Pharmacy Benefit Manager (PBM)?
- Is there documented cost savings from bundling medical and prescription benefits—and where is the reporting that validates those savings?
- Will the carrier share medical claims data with a carved‑out PBM to support clinical programs and cost‑containment efforts?
Most medical carriers already use external PBMs to administer their bundled prescription drug programs—evidence that specialized expertise is crucial in this field. For example, Horizon partners with Prime Therapeutics, Cigna with Express Scripts, UnitedHealth Group with OptumRx, and Aetna with CVS Caremark to manage prescription drug benefits for their employer-sponsored plans.
These relationships clearly demonstrate that medical carriers and PBMs do not operate on fully integrated adjudication or reporting systems. Yet they successfully and routinely exchange detailed medical and pharmacy claims and payment files. This proves that medical carriers can—and already do—work effectively with external PBM partners.
Importantly, medical carriers are not limited to sharing data with their affiliated PBMs. Most will also share medical data files with an employer’s selected carve‑out PBM, allowing care coordination, clinical programs, and cost‑management strategies to be implemented effectively.
These factors prompt additional important questions that remain unanswered:
- If a carve‑out PBM can receive the same comprehensive data as an affiliated PBM, why wouldn’t the medical carrier still be able to deliver the same—or better—cost savings?
- If coordination and data sharing can exist outside of a bundled arrangement, why do some medical carriers impose monetary penalties when an employer chooses to unbundle the prescription drug benefit?
Bring these questions to the table at your next meeting with your bundled medical carrier.
If you would like to discuss more about how Benecard can help assist in validating savings to your medical program through our Pharmacogenetics program and working with your medical carrier to cross share data files, please reach out to us at talktous@benecard.com.
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