2025 SOA Health Meeting: SSession 10B: Comprehensive PBM Performance Evaluations Including TCOC Impact -06.25.25- Recording

This session will instruct attendees on how to evaluate PBM performance comprehensively. Many PBM proposal evaluations conduct financial projections that compare the bidding PBMs' projected discounts from AWP, dispensing fees, other administrative and clinical fees, and rebates by taking a prior 12-month period of claims and 'repricing' them. When they project future performance based on the competing PBM's proposals, they 'reprice' the claim data, which means they trend forward unit prices (AWPs, ingredient costs, etc.) and utilization. Still, they do not typically evaluate how different PBMs' formulary designs and clinical programs (PAs, Step edits, etc.) shift prescription utilization within therapy classes.
This session will demonstrate such modeling and how to model the impact on Total Cost of Care (pharmacy claim experience and medical claim experience) due to different PBMs' formularies and clinical program designs. Sometimes, it is better to increase pharmacy benefit spend in order to drive medical claim cost savings. Itwill demonstrate how to comprehensively evaluate PBMs' impact on prescription utilization patterns within therapy classes and PBMs' impact on a payer's total cost of care.