A practical guide for brokers reviewing pharmacy claims, cost patterns, member experience issues and savings opportunities before clients start asking harder questions
Table of Contents
- Why pharmacy reviews should happen before renewal planning starts
- What your client's pharmacy claims are telling you right now
- The medications driving costs behind the scenes
- How to evaluate specialty drug spending
- Questions clients are likely to ask next
- Where pharmacy savings opportunities often hide
- Signs employees may be struggling with their pharmacy benefits
- The pharmacy data every client report should include
- Red flags that deserve attention before renewal season
- Turning mid-year pharmacy reviews into better client conversations
- Key takeaways
Why pharmacy reviews should happen before renewal planning starts
Pharmacy costs rarely stay flat throughout the year. A client may begin the year with a stable pharmacy budget and six months later find that one specialty medication, a handful of new GLP-1 prescriptions, or increased utilization has changed the financial picture.
That is why many brokers review pharmacy data long before renewal discussions begin.
A mid-year review gives you time to understand what is happening inside the plan while there is still time to address it. You can review claims activity, identify unusual spending patterns, and prepare recommendations before your client starts asking questions.
Clients are also paying closer attention to pharmacy benefits than they did a few years ago. They want to know where their money is going, why costs have changed, and whether employees are getting the value they expected from the plan.
The more familiar you are with the numbers, the easier it becomes to explain what is driving spend and where opportunities may exist.
What your client's pharmacy claims are telling you right now
Claims data can reveal patterns that are easy to miss when you only look at total pharmacy spend.
One of the first things to review is whether spending increases are tied to utilization, drug prices, or both. A higher pharmacy budget does not always mean more prescriptions are being filled. In many cases, the cost of a small number of medications accounts for a large portion of the increase.
GLP-1 medications are a common example. A review of year-to-date claims may show a growing number of members using these drugs or a sharp increase in spending tied to a small group of prescriptions.
It is also worth reviewing:
- The highest cost medications on the plan
- Drug categories generating the most spend
- Changes in utilization compared to the same period last year
- Member out-of-pocket costs
- Specialty medication activity
- New high-cost claims that were not present earlier in the year
Looking beyond total spend gives you a clearer picture of what your client is paying for and where attention should be focused.
The medications driving costs behind the scenes
Certain drug categories appear repeatedly when pharmacy costs begin to rise.
GLP-1 medications continue to receive attention because of their growing use and high price points. Depending on the plan design, they can represent a significant portion of pharmacy spend.
Specialty medications are another area worth reviewing closely. Treatments for autoimmune conditions, inflammatory diseases, cancer, and rare disorders often account for a large share of costs even when only a small number of members are using them.
Other categories that frequently deserve attention include:
- Diabetes medications
- Specialty dermatology treatments
- Migraine medications
- Fertility drugs
- High-cost injectables
- Long-term maintenance medications
Reviewing spending by category helps you understand where pharmacy dollars are concentrated and whether any areas deserve a deeper review.
How to evaluate specialty drug spending
Specialty medications deserve their own review because they often represent a large percentage of total pharmacy costs.
Start by identifying the medications generating the highest spend. From there, review how those medications are being sourced and whether members are using the most cost-effective pharmacy channels available under the plan.
You should also look at:
- Utilization changes during the year
- Prior authorization activity
- Site of care opportunities
- Rebate eligibility
- Alternative sourcing opportunities
- Member adherence patterns
A single specialty claim can have a significant effect on pharmacy spend. Understanding where those dollars are going helps you prepare more meaningful conversations with your client.
Questions clients are likely to ask next
Clients often notice pharmacy issues before they see the full data. An employee may complain about a high copay, a manager may ask why certain medications are difficult to obtain or someone may question why pharmacy costs appear higher than expected.
Before those conversations happen, review questions such as:
- Have member out-of-pocket costs increased?
- Are employees experiencing access issues?
- Are high-cost medications being managed appropriately?
- Have there been major changes in utilization?
- Are rebate opportunities being captured?
- Are members receiving support when pharmacy issues arise?
Having answers ready makes client conversations more productive and helps prevent last-minute surprises.
Where pharmacy savings opportunities often hide
Many pharmacy savings opportunities can be found by reviewing utilization patterns and prescription purchasing channels.
One area worth examining is brand drug utilization. Some plans continue paying for brand medications when lower cost alternatives are available. Reviewing these prescriptions can help identify opportunities to reduce spend without disrupting member care.
Another area is specialty medication sourcing. The same medication can carry very different costs depending on where it is filled. Reviewing specialty pharmacy channels, site of care arrangements, and dispensing locations may uncover savings opportunities.
You should also look at:
- Generic utilization rates
- Copay assistance opportunities
- Cost plus pricing options
- Formulary alignment
- Duplicate therapies
- Mail order utilization
- Pharmacy network performance
A review of these areas can reveal opportunities that may not appear in a standard pharmacy report.
Signs employees may be struggling with their pharmacy benefits
Member feedback often provides a clearer picture of how the pharmacy benefit is working in practice.
As the year progresses, employees may begin raising questions about coverage, medication access, prior authorization requirements, or out-of-pocket costs.
Common concerns include:
- Delays receiving approvals for medications
- Difficulty understanding coverage requirements
- High pharmacy costs at the point of sale
- Problems locating specialty medications
- Limited communication during claim issues
- Confusion around formulary changes
These conversations can help identify areas where additional support may be needed. They can also highlight issues that may become larger concerns during renewal discussions.
The pharmacy data every client report should include
A pharmacy report should explain what is driving spend, where changes have occurred, and what actions may be worth considering. Clients want information they can understand and use.
Useful reporting often includes:
- Total pharmacy spend year-to-date
- Top cost drivers
- Highest utilization drug categories
- Specialty medication spend
- Trends compared to previous reporting periods
- Member disruption concerns
- Savings opportunities identified during review
- Recommendations for the remainder of the plan year
Clear reporting helps clients understand where pharmacy dollars are going without requiring them to interpret complex claims data.
Red flags that deserve attention before renewal season
Some trends deserve a closer look as soon as they appear. Rapid increases in specialty spending can change the financial outlook of a plan within a short period of time. Significant growth in GLP-1 utilization may also affect future projections.
Other areas worth monitoring include:
- Unexpected increases in total utilization
- High brand dispensing rates
- Large cost increases tied to a small number of claims
- Growing employee complaints
- Frequent prior authorization exceptions
- Specialty medications filled outside preferred channels
- Rebate amounts that appear inconsistent with utilization patterns
Addressing these issues earlier gives you more time to evaluate options and discuss potential solutions with your client.
Turning mid-year pharmacy reviews into better client conversations
A mid-year pharmacy review gives you specific information you can bring into client conversations.
When you understand where pharmacy dollars are being spent, which medications are driving costs, and what employees are experiencing, discussions become more productive.
Clients are often looking for answers to questions such as:
- Why have pharmacy costs changed?
- Which medications are responsible for the increase?
- Are employees paying more out-of-pocket?
- Are there opportunities to lower costs?
- Are current pharmacy programs working as intended?
A mid-year review helps you prepare those answers before renewal planning begins.
It also creates an opportunity to discuss potential adjustments, review savings opportunities, and address concerns while there is still time to act.
Clients appreciate conversations built around their own data. Bringing clear findings, identified risks, and practical recommendations to the table helps keep discussions focused and productive.
Key Takeaways
- Review pharmacy claims before renewal planning begins.
- Identify the medications and categories generating the most spend.
- Monitor specialty drug costs and GLP-1 utilization.
- Review employee out-of-pocket costs and access concerns.
- Look for savings opportunities related to sourcing, formulary management, and generic utilization.
- Include clear pharmacy reporting that highlights cost drivers and utilization trends.
- Investigate warning signs such as rising specialty spend, high brand utilization, and recurring member complaints.
