A Future-Forward Pharmacy Benefits Model: 

Bundle or Unbundle Services

As pharmacy benefit management stakeholders seek alternatives to the traditional PBM model, they face a choice of bundled or unbundled services. They increasingly select best-in-class technology partners to manage multiple functions with a goal of delivering clarity, control and customization.

We will help our readers and clients across the healthcare ecosystem – from PBMs to health plans and health systems, self-insured employers and TPAs/brokers, workers’ comp, stop-loss, hospice, veterinary and more – to better understand the opportunities of a bundled or unbundled approach to the pharmacy benefit.  

Many are considering or exercising their options to choose an unbundled PBM model. For example, employers and health plans that implement an unbundled model often gain greater visibility into drug utilization trends, improved rebate transparency and enhanced control over formulary design, ultimately reducing overall drug spend while improving member outcomes. Several factors account for this shift:

1. Cost Control: As pharmacy benefit costs continue to rise, employers are looking for ways to manage these expenses more effectively. Unbundling allows them to have more control over the costs associated with pharmacy benefits.
2. Transparency: Traditional PBM models often lack transparency, making it difficult to understand where the money is going. Unbundled models provide greater visibility into the costs and operations of pharmacy benefits, helping employers make more informed decisions.
3. Flexibility: Employers are seeking additional flexibility in administering their plans. Unbundling allows them to tailor their pharmacy benefits to better meet the needs of their employees and their organization.
4. Popularity of GLP-1 Drugs: The recent popularity of GLP-1 drugs has highlighted the advantages of unbundled PBM models. These drugs are often expensive, and unbundling can help employers manage the costs associated with them more effectively.

Key Advantages of Flexible, Customizable PBMs

William Figueroa, Chief Information Technology Officer of RxLogic, points to the value of technology that features a modular design, granting customers the flexibility to choose and utilize specific components as needed, without the necessity of subscribing to the entire end-to-end system.

“While our customers can choose to subscribe to our Claims Adjudication Engine, they can also subscribe to Rebate Administration Services and Payables & Receivables Modules, which can standalone, or be integrated with the core Adjudication engine and each other,” he says. “The option of standalone services delivers unbundled capabilities and the benefits that come with them. Essentially offering tailored solutions to meet diverse requirements.”

Here are several advantages:

1. Flexibility: Modular PBM carve-outs allow customers to choose and utilize specific components as needed, without the necessity of subscribing to the entire end-to-end system. This flexibility enables tailored solutions to meet diverse requirements
2. Cost Control: By selecting only the necessary modules, employers can better manage costs and avoid paying for unnecessary subscription fees for services
3. Customization: Modular systems offer the ability to customize the PBM services to better align with the specific needs of the organization
4. Transparency: Modular systems can provide greater transparency in pricing and operations, helping employers make more informed decisions.

It is important to seek a partner that can properly manage integration challenges to ensure seamless patient care, including capabilities and resources to handle complex administration.

Benefits of a Fully Unbundled Model

A fully unbundled model, enables more informed decisions based upon a plan’s specific goals about whether to adopt modular PBM carve-outs or fully unbundled models. Success depends upon the ability to leverage technology that effectively coordinates care and maintains high-quality patient outcomes.

Benefits of a fully unbundled model include:

• Provides comprehensive control over all aspects of pharmacy benefits, allowing for more effective management.
• Offers enhanced transparency, ultimately reducing overall program costs while improving access to accurate data.

There are certain caveats that emphasize the value of selecting a partner that recognizes the importance of flexibility and offers a configurable platform with API-integration capabilities for optimal plan design. 

Figueroa adds, "Managing a fully unbundled model adds complexity and administrative burden, which is why a partner like RxLogic is essential— they provide the technology and vendor integrations needed to simplify operations."        

Ensuring Seamless Integration Across Multiple PBM Vendors…without disrupting patient care

Achieving this delicate balancing act requires a vendor to have robust integration and data access capabilities.

“The RxLogic system excels in this area by offering clients 100% direct access to their raw data, if desired,” explains Billy Buckles, SVP Product and Client Services at RxLogic. “This strengthens the client’s technology and operations environment and their ability to identify trends.”

Additionally, the model provides a comprehensive Client API Library, enabling clients to effortlessly push and pull data from the system using existing APIs and allows for API access and management within a particular environment.  This flexibility ensures smooth and uninterrupted patient care.

Some integration-use cases from RxLogic include:

1. Check Issuing Integration with Payables Manager in a Payables/Receivables module: This project added check issuing capabilities to this module, allowing for the automatic processing of payments through an external vendor. The integration included features such as physical checks, digital checks and ACH payments, ensuring seamless payment processing and tracking.
2. Accounts Receivable and Accounts Payable Integration: This integration involved the generation of invoices and claims detail for Accounts Receivable, as well as the generation of ACH for Accounts Payable. The project included rigorous testing and validation to ensure accuracy and full functionality of the integrated data.
3. Client Data Migration: RxLogic streamlines onboarding and facilitates the migration of claims, eligibility, prior authorizations, accumulators, network data and more using standard migration tools or APIs designed for real-time integration. This approach ensures minimal data loss and maximum efficiency, making the process smooth and scalable for future automations.

RxLogic System: Designed with Flexibility

Supporting both bundled and unbundled models, the RxLogic system is designed with flexibility at its core. This adaptability allows customers, including PBMs, to build and manage various rule sets tailored to their specific plan and benefit designs.

The workers’ compensation industry is another notable example of the value of flexibility to support both bundled and unbundled models. Specialized workers' comp PBMs, demonstrate significant cost savings by carving out benefits specific to workers' comp policies. 

Today, hospice and long term care PBMs also leverage the RxLogic system to achieve these efficiencies. The RxLogic modular design grants its customers the ability to choose and utilize specific components as needed, without the necessity of subscribing the entire end-to-end system. This level of flexibility and customization is built into the technology solutions which can adapt to the unique needs of various stakeholders across the healthcare ecosystem.

Supporting a diverse range of customers

Founded upon the pillars of flexibility and transparency, the modern, SaaS-based RxLogic technology platform empowers its customers with complete control over their data, environment and the services they offer.

“This adaptable technology is designed to support a diverse range of clients, including PBMs, retail chains, health systems, self-insured employers and others,” says Buckles. “By leveraging a user-focused web-based UI and API-first architecture, RxLogic equips the PBM ecosystem of stakeholders with powerful tools to better serve millions of individuals nationwide.

One of the standout features of RxLogic is its scalability and reliability.

Built on Microsoft Azure, the technology platform is highly reliable, supports large transaction volumes and isolates client workloads.  This ensures consistent and uninterrupted service.

Customization and flexibility are at the core of RxLogic's value proposition. Adaptable technology meets clients' unique requirements, reducing the need for manual adjustments and allowing for tailored solutions that meet diverse needs. This level of customization is particularly beneficial for clients with complex and varied benefit designs.

In addition to flexibility and transparency, RxLogic offers advanced payment and financial management capabilities through its Payables/Receivables module which streamlines the payment administration process. This enables clients to issue payments to contracted pharmacies through physical checks or ACH transfers (leveraging NACHA protocol standards). It also automates invoicing, receivables management and provides comprehensive remittance advice using ANSI X12 835 formats.

By providing these comprehensive and adaptable solutions, RxLogic ensures that its technology can meet the unique needs of various stakeholders across the PBM ecosystem.

“As more employers and healthcare stakeholders explore alternative PBM models, the ability to bundle or unbundle services without sacrificing quality, integration or oversight, is more important than ever,” concludes Figueroa. “At RxLogic, we give clients the flexibility to build pharmacy benefit solutions their way.”