Why You Need a Pharmacist on Your Side of the Table

As a plan sponsor, you’re tasked with managing one of the most complex and costly components of your benefits program: pharmacy. While Pharmacy Benefit Managers (PBMs) are a necessary part of the system, giving them full control can lead to misaligned incentives and missed opportunities.

With rising costs and heightened scrutiny on fiduciary responsibilities, having a clinical pharmacist on the team working for you—independent of your PBM—is more critical than ever. Here are five reasons why your organization needs a pharmacist-led consultant working on your behalf.

1. Strategy Backed by Clinical Expertise

Our pharmacy benefits consultants aren’t just advisors; they’re experienced clinical pharmacists. Their role is to help you:

• Evaluate formulary changes for both clinical and financial impact
• Create custom drug exclusion lists independent of PBM rebate structures
• Analyze member utilization to identify cost-effective, clinically sound alternatives
• Minimize member disruption with evidence-based recommendations

2. Address Specialty Drugs: The Biggest Cost Driver

Specialty medications are now one of the largest cost drivers in today’s health care landscape—for both employers and employees. Many PBMs only promote biosimilars they manufacture or market, limiting your options. A clinical pharmacist can help you build a true biosimilar-first strategy, identifying all available alternatives and ensuring decisions are based on clinical outcomes, not PBM incentives. This may include evaluating if a two-PBM model is right for you, with one dedicated to managing your specialty prescription spend.

3. Independent Evaluation of Clinical Programs

There are many clinical programs that promise value, but not all are right for your member population. One challenge in evaluating these programs is that many tie incentives to participation rates rather than outcomes. However, when your consultant isn’t paid based on program adoption, they can objectively evaluate whether each program delivers real value for your members and your bottom line. Many of these programs demand specialized knowledge of disease states and the medications associated with them—expertise that most benefit teams aren’t equipped to provide. This is where a pharmacist on your side of the table can provide an independent assessment of cost versus value.

4. Oversight of Utilization Management and Prior Authorization

Utilization management and prior authorization programs are essential, but they must be implemented thoughtfully. A pharmacist can review these programs to ensure they are:

• Clinically sound
• Aligned with your plan goals
• Not creating unnecessary barriers to care

5. Support Your Evaluation of the Booming Drug Pipeline

With hundreds of new drugs entering the market each year, no CFO, CEO or benefits leader can be expected to keep up. (Let’s face it, you’re probably not a pharmacist or physician.) But that doesn’t mean you should hand over the reins entirely. A clinical pharmacist helps you:

• Challenge PBM recommendations
• Ask the right questions
• Make informed decisions that uphold your fiduciary responsibility

The Bottom Line

Pharmacy benefits are too complex and too costly to manage without expert, unbiased guidance. A clinical pharmacist on your side ensures you’re not just following a PBM’s recommendations but proactively shaping a plan that provides transparency and protects your members and your budget.

If you are ready to level the playing field, one of our clinical pharmacists is ready to assist.