The Impact of Personalized Medicine in Pharmacy Benefits

May 31, 2023

Personalized medicine has the potential to revolutionize how we prescribe and use medications.

Abarca’s Vice President of Drug Pricing and Network, Nicole Bulochnik, shares the impact this emerging field will have for payers and PBMs:

How will personalized medicine change the way we approach pharmacy benefits?

Personalized medicine can alter pharmacy benefits in a few ways.

First, as personalized medicine becomes more prevalent and reliable, payers will need to cover new costs–like pharmacogenomic tests. However, because these tests help identify how an individual will respond to a particular medication, other costs (like those associated with trial-and-error prescribing or medication-related adverse events) will be reduced.

Payers will also be able to use results from pharmacogenomic testing to better automate the utilization management process (e.g., clinical review and prior authorization) and ensure therapies are covered for populations and individuals most likely to benefit from them.

Finally, personalized medicine could facilitate wider adoption of innovative drug contracts. With more consistent and clear expectations of how a drug will perform, payers and manufacturers will be able to engage in more meaningful negotiations around pricing and tying costs to value and expected outcomes.

What can payers/PBMs do to demonstrate the ROI of personalized medicine?

Before covering pharmacogenomic tests, it is vital that payers/PBMs determine their accuracy, precision, and applicability. 

They then need to assess the cost of tests and therapies relative to the cost of potential outcomes (both clinical and financial) to demonstrate clear, quantifiable insights about ROI.

For example, cost savings can be realized if a personalized medicine test reveals that a less expensive medication alternative can be used. Savings may also be generated through the avoidance of costly adverse outcomes (i.e., hospitalizations). 

What is Abarca’s approach to managing personalized medicine?

At Abarca, we focus on bringing our clients innovative products that drive value. When it comes to personalized medicine, that means streamlining the process to bring novel products quicker to our clients and partners.

So, we are currently in the process of researching, reviewing, and planning a pilot with a personalized medicine partner. As part of this program, we will be making it easy for payers to see how to incorporate these tests, assess the potential benefits, and determine the ROI as well as what success looks like for their plans and members.

Our team motto is to lower costs and focus on high-value care and eliminate waste.



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