The Hidden Costs in Medical Plans Driving Today’s Increases

Prescription drug costs are skyrocketing—especially specialty medications, which account for over 50% of pharmacy spend despite being used by just 1–2% of plan members. These rising costs are pushing many employers to rethink plan designs, often at the expense of employees.

Unfortunately, most employers lack the negotiating power and visibility needed to control these expenses effectively. That’s where Christi Group Pharmacy Solutions comes in.

Expert Guidance. Proven Strategies. Better Outcomes.

Our dedicated team of in-house Pharmacy Benefits Management (PBM) experts offers deep industry knowledge and access to cutting-edge tools to help employers optimize their pharmacy benefits and control costs without sacrificing care.

OUR COMPREHENSIVE SERVICES INCLUDE:

Prescription Drug Program Evaluations
Tailored assessments for employers of all sizes and industries to identify cost-saving opportunities.

RFP, RFI, and Renewal Support
Strategic oversight of vendor selection and market checks to ensure optimal contract terms.

PBM Contract Review & Negotiation
Expert analysis to uncover hidden fees and negotiate transparent, cost-effective agreements.

Specialty Drug Cost Mitigation
Consultative solutions to manage high-cost drugs, including alternative funding strategies and clinical controls.

Data-Driven Decision Support
Robust analytics that deliver clear, actionable insights for both financial and clinical impact.

Pharmacy Benefits Audits
From pricing and plan design to clinical oversight, we ensure your PBM is delivering what was promised.


SO, YOU THINK ALL PHARMACY BENEFIT MANGERS (PBMS) ARE CREATED EQUAL?

Below is what you could be paying for if you are NOT with the right PBM.

• PBMs do not include all-brand National Drug Code (NDC) for rebate aggregation, resulting in the PBM retaining it.
• PBMs do not pay on Over the Counter (OTC) rebates, although they collect and retain the rebates.
• PBMs do not pay on insulin rebates, although they collect and retain the rebates.
• PBMs collect and retain rebates on non-formulary drugs.
• PBMs do not pay on all diabetes supplies, although they collect and retain stated cost.
• Differentiating Pre & Post Average Wholesale Price (AWP), or 'Spread Pricing'
• PBMs pay pharmacies Post-AWP pricing
• PBMs charge clients Pre- AWP pricing, resulting in retainment of Spread
• PBMs may charge an administrative fee on reversed claims.
• PBMs adjust the number of drugs available for the rebate by changing the denominator of drugs rebated.
• PBMs adjust the denominator of the drugs to reduce the rebate amount
• PBMs only provide a portion of a point of sale rebates.
• PBMs utilize multiple Maximum Allowable Cost (MAC) lists:
• One MAC list for the client; Another MAC list for the pharmacy
• Clawbacks, revenues collected from the pharmacy, are 100% retained by the PBM.
• PBMs collect DIR Fees for not performing Medication Therapy Management (MTM) to the PBMs satisfaction.
• PBMs are responsible for manipulation of the Most Favored Nation (MFN) pricing.
• PBMs do not confirm that all pricing will be based on the AWP on the actual date the drug is dispensed.
• PBMs do not pass-through Usual and Customary (U&C) claims.
• PBMs take spread on compound claims.
• PBMs charge the client a professional administration fee for a vaccination, but do not pay the pharmacy
• PBMs may create spread on repackaged NDCs.
• PBMs negotiate a lower rebate but request a lower cost for the drug at the in-house PBM pharmacy
• PBMs negotiate a higher rebate by allowing slimmer early refill rules that increase the chance for an add'l fill per year.
• PBMs dispense 90-day supplies but charge the client for a 100-day supply.
• PBMs waive copays to steer towards mail order pharmacy.
• Zero Balance Due: Force shift 100% of patient pay into the contractual guaranteed agreement.
• PBMs reclassify drugs resulting in the PBM paying the pharmacy the generic cost and charging the client the brand cost.

Just to name a few.

The Christi Group Advantage
With Christi Group, you get more than a vendor—you gain a trusted local partner backed by national expertise and best-in-class pharmacy consulting. Our team is committed to helping you navigate the complex pharmacy landscape with confidence, from strategy to execution.

Better Pharmacy Strategies. Smarter Spend. Healthier Outcomes.

Let the Christi Group help you manage today’s challenges and prepare for tomorrow’s opportunities—with smarter pharmacy benefit strategies that deliver lasting value for your organization and your employees.