Why Gravie built a different kind of pharmacy benefit

By Marko Blagojevic, PharmD – Senior Vice President, Pharmacy

There seems to be no end in sight for soaring brand-name and specialty drug costs, and your clients are the ones paying for it.

Pharmacy is no longer a line item employers can set and forget. It now accounts for 25% of employer healthcare spending, and is expected to rise 12% in 2026 with overall health costs projected to jump 9.2% in 2027, according to Business Group on Health. Specialty drugs are the biggest reason: they now account for roughly 60% of total pharmacy spend, despite representing fewer than 5% of total prescriptions. The pipeline isn’t slowing either, since specialty therapies make up nearly 75% of the more than 7,000 drugs in active development.

For a self-funded employer, that means volatility. A single therapy claim can easily exceed $1 million, and these claims often catch self-funded employers off guard. Even with stop-loss protection, one claim can dramatically affect annual spend. When that happens, the employer is left holding the bag, and you’re the one fielding the call. 

Too many hands between the manufacturer and the member

A drug travels a long distance between its manufacturer and the person who needs it. Along the way, nearly every player in the chain is motivated to extract maximum revenue from the system. Rebates, discounts, spread and fees all create various incentives, and few of them point toward the lowest net cost for the member or the plan.

Employers have noticed. More than four in ten employers (41%) are either changing PBMs or running an RFP, with many being urged to explore PBM models that champion better clinical management and rely less on rebate optics. A tweak to plan design won’t fix that, but rather the model itself has to change. 

What we’re building at Gravie

This is the next phase of Gravie’s pharmacy benefit. We’ve built a program that is clinical-first, pharmacist-led, and designed with one goal in mind: drive to the lowest-possible cost, most clinically effective drug therapies for members and plan sponsors—not generate revenue for a PBM or a drug manufacturer. It’s an ever-evolving suite of programs aimed at lowering costs and increasing access while preserving quality and improving outcomes.

Three things set it apart.

• We actively manage the formulary. A traditional formulary is often a one-size-fits-all design that reflects where the revenue is. Ours is managed continuously to strive for the lowest net cost. High-value biosimilars and generics are highlighted over high-cost, low-clinical-value brand-name drugs, even when the pricey option is better for someone else’s bottom line.
  
• We manage utilization rigorously. Our pharmacists apply customized and comprehensive clinical coverage criteria and verify medical documentation where appropriate. That keeps high-cost drugs reserved for the patients who benefit most.
  
• Our pharmacists talk to members. This is the differentiator I’m most proud of. Gravie pharmacists reaching out directly to members, providers and pharmacies to work through their therapy, including optimizing dosage and finding lower cost alternatives. We resolve care gaps, catch errors and eliminate waste before they become claims. Our incentives always point members toward high-value drug therapies such as biosimilars over branded biologics.

A more proactive approach

One thing I like to tell our broker partners at Gravie is that we don’t wait for a problem to land on your desk. Our team of clinical and pharmacy experts works as an extension of yours.

• We pressure-test benefit setups, monitor claims in real time to catch coding errors and overcharges before they cause problems at the pharmacy counter or an HR director’s desk.
  
• We oversee our prior authorization, step therapy and quantity limit programs and workflows for accuracy and performance and they are continuously evolving to keep up with the evidence and changes in the drug pipeline.
  
• We also keep watching the PBM market, with regular RFPs and market checks to make sure rates stay as competitive as possible.

The point is that your client, their members and you shouldn’t have to chase these issues. The large national PBMs, by design, aren’t set up to do that work. Gravie is.

The bottom line

We’ve built a different kind of pharmacy benefit at Gravie, one that puts clinical judgment ahead of revenue and control back in the hands of your clients and their members. If you’d like to see what that could look like for a specific client, please get in touch.

If you’d like to discuss what Gravie’s pharmacy benefit could look like for your clients, contact a rep.