Making the Case for Carve-Out

Making the Case for Carve-Out

FlexScripts Administrators is very supportive of integrated health plans. Our goal has always been—and will continue to be—to manage the pharmacy benefit to encourage appropriate utilization and compliance of medications.

Carving out the prescription medication benefit helps clients maintain financial control, gives them greater clinical choices, and enhances leverage over the carrier.

Why Bundle in the First Place?

Carriers want the benefit bundled due to the fact the Rx benefit is the highest touch benefit, thus creating a higher barrier for the client to transition away. Over time this erodes the employers pricing leverage with the carrier.

Carriers offer little to no PBM client specific guarantee underwriting of financial guarantees, thus financial recovery via audit due to financial underperformance is almost nonexistent. Carrier contracts offer very little detail on performance obligations versus the carve out arrangements.

We Know You’re Unique

Clients and their employees/members are unique, and as such, their clinical oversight should be unique to fit their needs. FlexScripts has found over the years that pharmacy benefit designs should be developed to fit the employer patient populations, needs and coverage.

Coordinating pharmacy and medical care is critical to creating successful clinical outcomes. FlexScripts Administrator’s dedicated communication with medical case management, ensures that this happens.

Therapeutic Categories

We have seen numerous instances where pharmacy claims have been provided to a medical TPA only to find that the claims are merged with medical only for selected disease states.

FlexScripts intent is to view all disease states regardless of the cost of medications (i.e. low cost generic that was previously a high cost Brand). Some common examples include opiate addiction, testosterone supplementation, and mental health (depression, bipolar disorder).

Specialty Drug Specialists

FlexScripts specializes in helping deliver medications, in particular the “specialty” medications, by the most cost effective route. This may be via pharmacy with medical administration. Our focus is on the total cost (medical and pharmacy) rather than the traditional silo model.