The PBM Equation

WithMe Team

For a long time, price has been at the center of most decisions made in the pharmacy benefit space. Medication price guarantees are at the heart of any PBM RFP process, with the winner typically being the lowest bidder. Employers have formed coalitions to increase their purchasing power in efforts to secure lower medication prices.

Price is an appealing focus because it is the simplest component of quantifying pharmacy spend. But pharmacy spend is the product of medication price and utilization. Utilization - or the choice of what’s prescribed, how much, for how long, and whether it’s working - is often overlooked as a key driver of spend and thus as a significant lever for savings.

Purchasers often deprioritize utilization in the pharmacy buying process because it requires specialized expertise to quantify.

Additionally, traditional PBMs have had limited tools for managing utilization and few incentives to improve upon them.

Typically, utilization management programs have focused on upfront medication selection as a way to control spend, earn rebates and promote patient safety, using tools such as the formulary, prior authorizations (PA) and step edits. Unfortunately, these are blunt instruments and were designed with little consideration for the member experience. We can do better.

Because the touchpoint with the member has been limited to point-of-purchase transactions, there has been little ability to influence the latter half of the medication journey. This interaction does not offer insight into the patient’s adherence or response. In an ideal healthcare system, the provider plays this role. The provider would see the patient regularly and assess whether the medication is working by running tests, conducting exams, and/or asking the patient about side effects and adherence.

In reality, there are many barriers to these interactions. Office visits require patients to spend time and money, both of which are significant barriers. Providers themselves are often stretched thin, with packed schedules, short appointment slots and tons of paperwork.

Things are missed.

In an imperfect world, PBMs can and should do better.

We need to interact more frequently with the patient, in a light-touch way that demands little of their time or energy. We need to double down on appropriate medication selection but, even more importantly, on patient guidance.

What does stellar utilization management look like?

#1. Personalized medication, dose and site selection

Is the patient prescribed the right medication in the right amount at the right time? Can they fill it and pay for it? The right medication will be the one that, given the patient’s profile, is most likely to optimize efficacy, while supporting safety and adherence by having a cost, side effects, and a dosing schedule that are tolerable for the patient. Dose and site of service considerations are also crucial for effective therapy and controlling employer spend, particularly around speciality medications, whose costs have grown exponentially in recent years.

All PBMs can do this. But we think we do it a little better. Here’s why:

Our clinical protocols have significantly more detailed criteria than a typical PBM. This, combined with our use of a member’s medical, lab, pharmacy and patient-reported data enables us to personalize their medication coverage (personalized formulary), and determine the best medication, dose and site of service for the individual.

Each personalized formulary is dynamic. It updates not only with the patient’s latest data but also with the latest clinical trial data and clinical practice guidelines, rather than relying on single-sourced and static data, such as FDA labels. We’re proud of this, and we’re always happy to discuss how we evaluated any medication.

We provide decision support to prescribers right at the point of prescribing via Real Time Benefit Checks which occur within the EMR workflow. This not only greatly reduces the number of hard stops patients and prescribers encounter, but also gives the prescriber instant access to the latest and personalized data-driven recommendations for their patient.

Whenever possible, we incentivize members to make changes rather than use hard stops, such as prior authorizations. Change is hard. We believe that changes that impact members should also benefit them whenever possible, (e.g. by applying in-app personalized savings).

Getting these things right - upfront medication, dose and site selection, as well as member compliance - reduces a tremendous amount of waste, while at the same time improving outcomes, helping to lower downstream medical costs.

#2. Patient guidance

The second step - and where WithMe Health really differentiates itself - is patient guidance.

We have a team of clinical pharmacists called Medication Guides who support the patient through the entirety of their medication journey: initial fill, starting therapy, staying adherent, validating a response, and, if unresponsive, facilitating a switch.

Guides reach out by phone or via our app to meet patients where they are - their phone. Quickly, Guides determine: Is the patient taking their medication? Is it working? This outreach is available to all members but we prioritize those who are high-risk and/or high-cost.

This follow-up is critical for both patient health and employer spend. Not all patients respond to the selected medication. In fact, clinical trials show a high rate of non-responders for many medications. For example, Humira has long been the top revenue grossing prescription drug in the world, yet it is only effective in 1 out of 4 Rheumatoid Arthritis (RA) patients[1,2,3]. In other words, for 75% of patients, Humira will not work.

For Humira patients, our Guides use the RAPID-3 assessment to identify those who are not responding (and for whom the spend is not providing a clinical benefit). The RAPID-3 is a great example of how a PBM can and should meaningfully complement a provider’s efforts to improve patient care. The assessment consists of three patient questions and relies only on a patient’s self-report of symptoms. We can reach the patient by phone or app and ask them three quick questions, and understand whether they are one of the 25% who responds successfully to Humira, or one of the 75% who do not.

In addition to administering tele-assessments, our personalized guidance incorporates other data, such as a patient’s lab tests, when available.

When a patient is unresponsive, we do two things: follow up with providers to share the clinical assessment and recommend moving on to the next line of therapy. No one - not the patient nor employer - benefits from the patient remaining on medication that is not working.

These interventions have real value, both to patients’ lives and to employers’ healthcare spend.

Effective management can significantly lower spend every year, resulting in a more sustainable trend.

If today your pharmacy spend is $10 million, and you can slow the growth from 8% annually to 3%, by 2025 you will have saved $8.7M. And at $11.6M instead of $14.7M, your annual spend will be 21% less than it would have been. In the years to come, this gap will only continue to grow.

In the equation of spend = price x utilization, no one can afford to overlook utilization. In an era of rising medication prices, effective utilization is essential to flatten the curve. To quantify the impact of better utilization requires expertise. To implement better management requires sophisticated systems for medication and patient guidance. We strongly believe both are worth the investment, not only to achieve short and long term savings, but also to improve member health and experience.

At WithMe Health, we’d love to share how we can help you with this and we’ll put a significant portion of our fees at risk to prove that we can.


1. Furst DE, Schiff MH, Fleischmann RM, et al. Adalimumab, a fully human anti tumor necrosis factor-alpha monoclonal antibody, and concomitant standard antirheumatic therapy for the treatment of rheumatoid arthritis: results of STAR (Safety Trial of Adalimumab in Rheumatoid Arthritis). The Journal of Rheumatology 2003;30(12):2563–71.

2. Keystone EC, Kavanaugh AF, Sharp JT, et al. Radiographic, clinical, and functional outcomes of treatment with adalimumab (a human anti–tumor necrosis factor monoclonal antibody) in patients with active rheumatoid arthritis receiving concomitant methotrexate therapy: A randomized, placebo-controlled, 52-week trial. Arthritis & Rheumatism 2004;50(5):1400–11.

3. Weinblatt ME, Keystone EC, Furst DE, et al. Adalimumab, a fully human anti–tumor necrosis factor α monoclonal antibody, for the treatment of rheumatoid arthritis in patients taking concomitant methotrexate: The ARMADA trial. Arthritis & Rheumatism 2003;48(1):35–45.