Behind the scenes, pharmacy benefit managers (PBMs) like Express Scripts help members and their plan sponsors in numerous ways. Because they serve millions of people, PBMs are able to use their negotiating power to increase competition and drive down costs. PBMs utilize software that works in the background to protect patients, screening every prescription before it is filled and flagging issues such as nonadherence, late refills that might indicated missed doses, and possible drug interactions.
Two-thirds of American adults use prescription drugs; this year, they will fill an estimated 4.9 billion retail prescriptions. “By a large margin, our clients tell us that pharmacy is the most used benefit among their member populations,” said Jen Awsumb, vice president of product management for Express Scripts, the pharmacy benefits management business of Evernorth, a subsidiary of The Cigna Group. Express Scripts serves more than 100 million Americans. “We are dedicated to assuring they can fill their prescriptions as easily, efficiently, and affordably as possible,” she said.
Drug safety and cost information is at the prescriber’s fingertips
Express Scripts recently rolled out enhancements designed to help further streamline the process while increasing members’ visibility into the total price of their medicine and the amount their plan has determined they should pay for each prescription. These enhancements also can aid prescribers – including doctors, physician assistants, and nurse practitioners – who use electronic health records (EHRs) to transmit prescriptions to pharmacies. Express Scripts’ real-time prescription benefit technology is integrated into EHRs and can inform prescribers and patients about costs, coverage, and potential safety issues before the prescription is transmitted to a pharmacy.
“With this information, doctors and other prescribers can see if the medication is preferred or nonpreferred on the formulary for the patient’s plan, which affects what the patient will pay at the counter,” Awsumb said. “The prescriber also sees information about any alternative medications that are clinically equivalent but would cost less, both for their patient and their plan.”
Members can go online for information and savings opportunities
Express Scripts’ member website also offers new functionalities to help people get the most out of their prescription benefit. For example, they can learn how and where to fill a specific prescription to get the best price according to their plan design.
“When you go to urgent care or see your doctor for a medical issue, you often don’t know what your cost for the visit will be until you receive an explanation of benefits days or weeks later,” Awsumb said. “When you fill a prescription, that’s not the case. You know right away what portion of the cost you are responsible for and what your plan will pay. This cost transparency is one of the ways that PBMs help their members understand the cost of their care.”
Even more information is available after members fill a prescription. Express Scripts is rolling out a digital pharmacy benefit statement that includes drug price information, the cost to the member’s plan, the amount the member pays – and how much they saved.
“While health care charges and total costs can be opaque, our digital pharmacy benefit statement is transparent in showing the value of PBMs,” Awsumb said.
Express Scripts technology: A behind-the-scenes safety net
Many patients have more than one doctor, and those doctors may not have complete visibility into every medicine their patient is currently taking – especially if the medical practices are affiliated with different health systems. In fact, a recent study by Express Scripts and the Regenstrief Institute found that more than 22,000 patients in the United States are exposed to potentially dangerous drug interactions each year because their health care providers lack visibility into complete medication history and other essential information.
PBMs process each of a patient’s prescriptions, from all prescribers, providing an opportunity to use this full view to help make people healthier. Express Scripts processes all claims – about 1 billion annually – under a single platform, using a unique patient identifier (UPI) that enables the PBM to help identify potentially serious interactions across insurance plans. This technology includes a complete, up-to-date list of prescriptions for each person, which allows the utilization management tools embedded in Express Scripts’ technology to alert pharmacists to potentially harmful drug interactions and other issues before the medicine is dispensed. This wealth of data also enables personalized outreach to patients and their physicians about drug therapy concerns. In 2023 alone, Express Scripts utilized its data and technology to send 12 million therapy-related safety and health alerts to prescribers, which promoted their patients’ health and prevented adverse events.
“While these sophisticated safeguards run in the background, invisible to patients, our technology and know-how help guide them and their prescribers toward the safest, most cost-effective drugs,” Awsumb said. “We are committed to ensuring members get the medication they need, when they need it, and for the lowest possible price.”
