Hospice PBM, or Pharmacy Benefit Management, is an important part of the hospice care provider. Below, we have compiled everything you need to know about Hospice PBMs and the benefits of utilizing one for your Hospice Organization.

What is a hospice PBM?

A Hospice PBM (Pharmacy Benefit Manager) is a company that provides hospice organizations with a network of pharmacies to offer competitive drug pricing and many other services. They are responsible for managing the contracts and costs for all the pharmacies that a hospice patient may use. Hospice PBM services are designed to help hospice care providers manage the cost and utilization of medications, as well as to provide access to discounted medications.

The primary goal of a hospice PBM is to ensure that medications and supplies are available when needed and are taken properly. Another service they provide is working directly with the hospice medical director to determine which medications are most suitable for each patient while considering the cost of the drug and how interacts with all other medications that the patient is on. In addition to managing the entire pharmacy side of hospice care, a Hospice PBM also provides support with compliance, pharmacy audits, prior authorizations, medication profile reviews, electronic prescribing, formulary utilization, clinical guidance, and call support for your Hospice Organization.

What services do hospice PBMs provide? 

Formulary Management

A formulary is an organized list of medications to aid nurses and other hospice staff in making decisions about what medications are appropriate for hospice according to a patient's diagnosis. The Hospice PBM will work with the Hospice Organization to create a formulary that offers the flexibility necessary for end-of-life care while maintaining a standard of prescribing habits for cost containment.

Discounted Drug Pricing

Hospice PBMs secure better drug prices than a Hospice Organization would be able to get on their own. This is especially true with national chain pharmacies. PBMs contract and negotiate prices with pharmacies. Negotiation is the keyword here. Without a Hospice PBM, a Hospice Organization pays a “retail price” for all drugs.

Clinical Guidance

Most hospice nurses don’t have access to their Medical Director for questions. However, Hospice PBMs provide your Hospice Organization with available pharmacists and other clinical experts to offer guidance for all things related to end-of-life care.

Medication Profile Reviews

A Medication Profile Review is part of the Comprehensive Assessment that must be completed no later than 5 calendar days after the election of hospice care. A Medication Profile Review is a review of all the patient’s prescription and OTC drugs, herbal remedies, and other alternative treatments that could affect drug therapy. This includes but is not limited to, the identification of the following: Effectiveness of drug therapy, Drug side effects, Actual or potential drug interactions, Duplicate drug therapy, and Drug therapy currently associated with laboratory monitoring. Hospice PBMs check for all the above while also checking for cost-saving alternatives.

Call support

Both your Hospice Organization and the pharmacies that your patients use will have access to the call support team of your Hospice PBM. This call support is available to help with anything from general inquiries to emergencies.

E-prescribing

Electronic prescribing is slowly becoming the norm to replace the outdated method of faxing prescriptions. A Hospice PBM will assist your Hospice Organization with transitioning from faxing prescriptions to sending them electronically. E-prescribing is a safer and more convenient way for Hospice Organizations to send prescriptions for both controlled and non-controlled substances to the pharmacy.

Local Pharmacy Network

Securing a reliable pharmacy network that covers all the areas in which your Hospice Organization provides care is accomplished with the help of your Hospice PBM. They take care of all the contracting on behalf of your Hospice Organization. Your Hospice PBM will work directly with the local pharmacies to craft a “Comfort Kit” specific to your Hospice.

Mail-order Pharmacy Network

Ordering medications via mail order must be done electronically. With the help of your Hospice PBM’s E-prescribing solution, your Hospice Organization will have the ability to order routine medications and have them delivered directly to the patient’s home or facility. Mail-order is only ideal for routine medications because of the standard two-day shipping.

Reporting and Analytics

By using a Hospice PBM for your Hospice Organization, you will have access to reports designed to help your hospice lower pharmacy costs and improve efficiencies. The data provided in these reports makes improving all aspects of medication utilization inevitable.

Regulatory Compliance

As with any healthcare organization, compliance is not something to overlook. Your Hospice PBM will assist your Hospice Organization with compliance in every way that they can.

Consolidated Billing

This is an easy service to take for granted. However, Consolidated Billing is one of the very best services that your Hospice PBM provides. Your Hospice PBM essentially functions the same as a credit card. You use your credit card to pay for groceries, clothing, furniture, etc. At the end of the month, you receive a bill from your credit card company showing all the items they paid for on your behalf. This is very similar to how your Hospice PBM operates. So instead of paying each pharmacy individually and directly, your Hospice PBM pays them all individually and directly.

Online Education for CE Credits

Not all Hospice PBMs provide this service, but it’s worth finding out if they do. Some Hospice PBMs provide access to online education for their hospice customers. This can save your Hospice Organization a significant amount of money.

EMR integration

Hospice PBMs require patient information. Specifically, patient information that is held within your hospice Electronic Medical Record (EMR) Software. How you get this information to your Hospice PBM varies. The best and most efficient path is via EMR Integration. Not all Hospice PBMs provide this service, but it’s worth finding out if they do. An EMR Integration allows your EMR and your Hospice PBM to share patient demographics and medication profiles across a secure channel. This takes away the need for hospice staff to manually fax, call, email, or upload patient data to the Hospice PBM.

Prior Authorizations

Your Hospice PBM will set up protocols and specific contacts at your Hospice Organization who are able to provide approval for medications that have been rejected at the pharmacy. Rejections can occur due to price, not being formulary, refilling too soon, and many other reasons.

Price Blocks

Your Hospice PBM can set up what is called a “Price Block” to protect your Hospice Organization from high-cost medications. The way it works is simple. If your Price Block was set at $100, the result would be that no pharmacy could fill a medication that exceeds that price. It will ALWAYS reject and require your Hospice PBM to call an approved hospice contact to give either approval (Prior Authorization) or allow the rejection to stand. Price Block allows your Hospice Organization to never be surprised by high-cost medications.

CR 8358 file (Med Fill File)

On January 1st, 2014, CMS released a new requirement for Hospice Organizations. This was the Change Request (CR) 8358. Your Hospice PBM takes care of putting together the Med Fill File containing all the hospice-covered medication claims that each hospice patient had during a given time. Hospices that do not use a Hospice PBM have to manually put together this file to submit to CMS.

What are the benefits of using a hospice PBM?

Using a Pharmacy Benefit Manager (PBM) for your hospice can be incredibly beneficial for patients and their families. PBMs equip your hospice clinical staff with tools, guidance, reporting, and dependable pharmacies. All these tools and services result in an efficient, cost-effective, informed, and compliant Hospice Organization capable of providing patient care on a level that all end-of-life care should be at. Using a PBM for your Hospice Organization is no longer a debated subject. Hospices that use PBMs have fewer costs, more technology, far better data, and steady growth. Using a Hospice PBM for your Hospice Organization is both financially and logistically logical.  

 Learn more about Hospice PBM pricing

Now that you know how beneficial a Hospice PBM can be for your Hospice Organization, you are probably wondering where to go from here… The way we see it, you have two options:

1. If you already work with a Hospice PBM, give yourself a pat on the back! You’re already taking advantage of great savings and other services!

2. If you don’t currently work with a Hospice PBM or aren’t thrilled about your current Hospice PBM, you should reach out to PDC Rx!

 PDCR Rx has been in the hospice industry for 22 years helping hospice care providers all over the nation. As one of the very last privately-owned and operated Hospice PBMs, PDC Rx continues to exceed expectations of what a Hospice PBM can do for a Hospice Organization. PDC Rx offers all the typical services that other hospice PBMs provide, as well as additional services that help hospice providers improve patient care and lower overall cost. All our additional services are included in our price. There are no hidden fees to be afraid of with PDC Rx. We truly believe that being personal and transparent is the only way to do business in the hospice industry. That’s why with PDC Rx, it is never business. It’s always personal.

Jordan Evans - Director of Business Development | PDC Rx