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Auto-Refill, Or Auto-Profit?

Video
April 05, 2022
By: Josh Golden

If your PBM owns a retail or mail order pharmacy, they’ve probably encouraged you to turn on an “auto-refill” feature for your plan.  But did you know that this feature can leave patients with more drug quantity than they can actually use in a given year?  Guess who’s paying for all that excess supply…

Transcription

In my last video, I encourage plan sponsors to hold their PBMs accountable for the performance of their prior authorizations. Today, I'd like to tackle the topic of auto-refill. Now, auto-refill is a plan design feature that automatically triggers the dispensing of a refill prescription, a specific number of days after the prior prescription was dispensed.

Many PBMs, especially those that own mail-order pharmacies encourage their clients to turn this auto-refill feature on. They argue that it promotes better drug adherence, but when it comes to PBM business practices details matter. In some cases, these PBMs will set the refill trigger to occur earlier than necessary, say 60 days into a 90-day therapy cycle. This means that by the end of the year, the plan sponsor has paid for 18 months of therapy. That's 150% of what the patient needed for the year. And what's more, PBMs may turn this auto-refill feature on indiscriminately, triggering refills for prescriptions that may not even be appropriate for long-term maintenance use.

Now, the benefit to the PBM is obvious that's 50% more revenue flowing through their mail-order facility. Unfortunately, you as the plan sponsor, end up paying for the systemic wastage. So here's a question that you should ask your PBM today. Can you show me a report of all members who received more than 365 days of therapy for any drug over the past year?

If you're worried about handling patient-level data, just have them provide a blinded report. Now, if that report shows multiple plan members with significant overutilization, that's a clear sign that your PBMs auto-refill feature is working to their benefit at a cost to you.

Now we've got one more video coming your way to round out the three questions that you should ask your PBM. So stay tuned!

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