What is a Member-First PBM?

Many PBMs understandably emphasize member experience and customer satisfaction in their marketing and customer-facing communications. But what does “member-first” really mean? How does it show up in interactions with plan sponsors and members, and can it be measured?

In our case, that simple statement is woven into our DNA and was a foundational to how the business was built from the start.

DisclosedRx was founded in March 2020 by Zack Robinson, Ken Kemker and Dan Rush.

Zack and Ken were industry executives. Dan was an entrepreneur with experience in scaling businesses, operations and sales. The three shared an idea about how a PBM should work: one source of revenue, no hidden incentives, and a business model that doesn't put doing well and doing right at odds with each other.

That idea has shaped the company since the beginning, including the way it is paid and the way its people work with members.

The founders have a simple way of putting it: “We do the right thing, even when no one is looking.”

It starts with the way the PBM is paid

The founders believed the business model mattered because it shaped the choices a PBM could make. If a company can earn more from a more expensive drug, a retained rebate or a particular pharmacy arrangement, its financial interests may not line up with those of the plan sponsor or member.

DisclosedRx was built around a different model. The client is the single source of revenue, drug pricing is passed through at 100%, and rebates are credited to the client in full. The formulary is managed around evidence-based, high-value drugs rather than to generate rebates.

What a member sees is whether someone helps when a prescription costs too much, when a claim is rejected or when something goes wrong during a plan transition.

The savings program

One member taking Imatinib, a daily medication for chronic myeloid leukemia, was paying about $500 a month.

Through the DisclosedRx Savings Program, Alternative Sourcing brought her cost down to roughly $100. She continued taking the same brand, at the same dose, from the same manufacturer.

The Savings Program is built around situations like this. It uses several avenues to reduce what members pay, including manufacturer assistance programs, Alternative Sourcing through international and domestic 340B-licensed pharmacies, and manufacturer copay cards.

A Savings Advocate handles the work with the member. That can mean figuring out which program applies, working through provider paperwork, coordinating with the pharmacy and staying involved through subsequent refills.

The work doesn't necessarily end once the initial savings have been found. If a copay card runs out during the year, for example, the advocate looks for another option.

For the person taking the medication, the difference between $500 and $100 each month is not a pharmacy-benefit metric. It's part of the household budget.

That is why the founders have always talked about fighting for every penny of savings.

Then there are the problems that happen at the pharmacy

A member can still run into problems after the price of a prescription has been worked out. A claim may be rejected. A prior authorization may be missing or need to be renewed. These are familiar problems to people who work in pharmacy benefits.

That's where Member Advocates come in.

They work with pharmacies on rejected prescriptions and unexpected copays, coordinate prior authorizations with prescribers' offices and help members work through whatever needs to happen next.

They can also compare pharmacy prices before a prescription is filled. Two pharmacies four miles apart may charge different amounts for the same generic medication. Knowing that before filling the prescription gives a member the opportunity to choose the less expensive option.

When a sponsor switches to a new PBM

DisclosedRx requests claims history and open prior authorizations from the outgoing PBM 60 to 90 days before go-live. That gives the team time to work through existing authorizations before the new benefit begins, rather than leaving a member to discover a problem after the transition.

These are ordinary parts of managing a pharmacy benefit. They are also the moments when a member is most likely to notice whether the people behind the benefit are actually helping.

The idea behind member-first

The three founders started DisclosedRx with a particular view of what a PBM should look like. The company should have a clear source of revenue. Its financial incentives should be visible. And the people working with members should have the ability and the responsibility to look for ways to make the benefit work better for them.

Over time, that has meant building the Savings Program, putting Member Advocates to work in supporting members, and writing the financial commitments into the contract.

It also means paying attention to the less visible parts of the member experience. Finding a lower-cost source for an expensive medication. Calling a doctor's office about a prior authorization. Checking another pharmacy before a member pays more than necessary. Making sure an existing authorization does not disappear when a plan changes.

The founders started DisclosedRx with a particular idea about how a PBM should work. The Savings Program and the people behind it are where that idea becomes real, one prescription at a time.