By Healthesystems
With prescription drug spend representing less than 10 percent of workers’ compensation costs, the role of Pharmacy Benefit Managers (PBMs) is often viewed as niche – and sometimes this role is not well understood. As public discourse around PBMs in group health intensifies, it’s helpful to understand the goals and responsibilities of workers’ comp PBMs and the constraints under which they operate.
Put simply, PBMs manage pharmacy programs for the payers of workers’ comp claims. But their value goes far beyond transactional oversight. A good workers’ comp PBM will remove barriers to care, mitigate therapeutic risk, and create workflows that make it as easy as possible for injured workers to recover – guiding pharmacists, physicians, and claims professionals through a complex system where every decision must align with regulatory requirements and evidence-based care. These objectives reflect an expanded role versus group health, where this level of complexity simply doesn’t exist – and where PBMs may be focused on other priorities.
Let’s look at the important roles workers’ compensation PBMs play in the complex workers’ comp ecosystem:
Optimizing Utilization and Cost of Prescription Drug Therapy
Workers’ compensation PBMs serve as clinical and operational partners in optimizing prescription drug therapy, helping to ensure that injured workers get the right drugs, at the right time, and at the right cost for the payer. They apply strategies to help control costs, often proactively working with physicians and pharmacies to recommend therapeutically equivalent alternatives that may be less expensive, such as generics, without compromising clinical outcomes. But more importantly than that, PBMs help to ensure therapeutic safety.
Critically, PBMs have played a transformative role in helping to mitigate systemic risks such as opioid overutilization – which historically has come at great detriment to injured worker patients and claims outcomes. PBMs like Healthesystems stepped in to flag these prescriptions and intervene when they were clinically inappropriate or being overutilized. In partnership with many others across the industry, these efforts have been instrumental in helping to overcome the opioid epidemic.
Managing Formularies to Support the Most Effective Care
Unlike group health, where formularies and drug access are primarily driven by economic factors, workers’ comp PBMs work within a narrower clinical scope – but with far more nuance. By implementing and managing formularies, PBMs support efficient and effective care for injured workers.
Not only do formularies help ensure patients get the right drugs at the right time, but they also help to streamline the prescription process when applied strategically. PBMs can design and manage complex formularies to reflect the unique needs of workers’ comp populations, ensuring alignment with evidence-based guidelines and regulatory frameworks.
For instance, prescription drug therapies for specific types of workers – such as firefighters – may not be included in standard drug formularies. This could mean increased friction for the injured worker at the pharmacy counter, as the necessary medications may trigger prior authorizations that can delay care. This may also cause difficulty for claims professionals, who will be required to spend time reviewing and approving the prescription.
The solution? Payers with these occupations in their covered populations can partner with their PBMs to create customized formularies. By using population-specific formularies, PBMs can provide access to timely treatment and improve the experience for both the injured worker and the claims team.
Providing Right-Time Information in Claims Processing
Worker’s comp PBMs don’t dictate treatment decisions; instead, they facilitate informed choices through tools like prior authorization, clinical guidance, and real-time support. They can help adjusters navigate increasingly complex medication landscapes, ensuring that care is both appropriate and timely.
To this end, PBMs often offer intuitive and easy-to-use claims tools to help claims professionals manage prescription drug activity. This can include providing real-time access to prescription drug data, embedded clinical guidance, report generation, intuitive workflows that simplify – or escalate, if needed – the authorization process at the point of sale, and more.
But where the magic really happens is when a PBM goes beyond transaction-level support to provide an aggregated view of risk to the claims professional. This can help claims adjusters come to the right conclusions to ease and streamline care for injured workers. For instance, when a claims adjuster is presented with a prior authorization for an opioid, and they are given real-time visibility into factors such as cumulative morphine milligram equivalent (MME) for the claim, estimated supply on hand, and prior authorization history – their decision may be very different than it would be without this added context.
Engaging and Ensuring Safety for Injured Workers
PBMs can help injured workers to understand the often-complicated workers’ comp system. For example, when a claim is first opened and timeliness is key, PBMs can quickly put important information in the injured worker’s hands – even making it possible to complete and submit documentation right on their phone.
When a medication is prescribed, PBMs provide clinical oversight to ensure that the drugs are appropriate for the diagnosis and do not interact negatively with other drugs the patient is taking. Then, at the pharmacy counter, PBMs ensure that injured workers receive their prescribed medicines promptly and without having to pay for the drugs.
As the claim progresses, PBMs continue to play a role. They can facilitate intervention processes that address drug therapy concerns with prescribers or even directly with injured workers. These high-touch clinical review processes may include:
- Analyzing an injured worker’s therapeutic regimen in the context of their entire medical history to uncover hidden or overlooked concerns
- Communicating recommendations to improve drug therapy safety and effectiveness to the prescriber
- Conducting one-on-one consultations with injured workers to review their medications for safety concerns, discuss side effect management, emphasize the importance of adherence, or address any other factors that may impact the safety and effectiveness of their drug therapy
Providing Specialized Consultative Expertise
In the complex workers’ comp ecosystem, the value of a PBM with specialized domain expertise cannot be overstated. A PBM that is purpose-built for workers’ comp understands the regulatory nuances, population-specific risk, and therapeutic challenges unique to injured worker care. This specialization enables more precise formulary design, targeted clinical strategies, and proactive risk mitigation capabilities that generalist PBMs may overlook.
This also includes specialized personnel: clinical pharmacists who are not only experts in pharmacology but also deeply versed in the intricacies of workers’ compensation. Their ability to apply pharmaceutical knowledge through the lens of injured worker care makes them a critical resource for shaping effective pharmacy management strategies.
Through it all, transparency and collaboration are key. Workers’ comp PBMs are not gatekeepers – they’re partners. Ultimately, their job is to prevent small issues from becoming big ones, and to support the injured worker’s path to recovery.
For a more detailed look at what workers’ comp PBMs do, check out our Workers’ Comp Solutions.
