What we’re watching

In a disaggregated pharmacy model, the claims processor is the most consequential decision a payer makes, because adjudication is where every formulary rule, clinical edit, and benefit provision is enforced or ignored.

GLP-1s can deliver meaningful value for the right members, but coverage alone is not a strategy. Employers need clear eligibility criteria, careful dose titration, early member education, lifestyle support and medication visibility to make a long-term investment more likely to hold.

Drug pricing benchmarks, discounts and rebates do not show whether a pharmacy benefit is actually performing. Employers and brokers should evaluate what the benefit prevents, including avoidable risk, unnecessary therapy and downstream medical costs, alongside what it pays for drugs.

Pharmacy benefit costs often rise when prescriptions move forward without enough clinical review. In this article, Dr. Martty Martinez-Fraticelli explains how duplicate therapies, high-risk interactions, and other drug-related problems can increase both patient risk and plan cost when they are not…

AI creates the most value in pharmacy benefit management when it identifies clinical risk before a medication is dispensed, not after a claim is paid. The strongest approach combines AI’s ability to detect patterns at scale with pharmacist review and clinical judgment.

Medication errors in pharmacy benefit management are not just clinical problems. They are also a major source of avoidable cost. In this article, Dr. Martty Martinez-Fraticelli shows how dosing errors, duplicate therapies, and drug interactions often move forward under models built to process…