Misclassifying drugs as specialty vs. generic can lead to significant loss of savings for employers. For example, a specialty drug (Revatio) can be reclassified as the generic equivalent Sildenafil Citrate (see below)
PBM A did not reclassify the generics and honored the generic discount guarantee at 87%. PBM B misclassified the generics as specialty, therefore the generic discount was dropped to 31%.
The impact of a 56% positive differential with PBM A on this subset of generic drugs is $1 M.
PBM A correctly classifies generic drugs. PBM B misclassifies generic drugs used to treat specialty conditions as specialty drugs.
PBM A classified the drugs correctly, and reports that the 21% specialty discount guarantee was not met by 1% and pays the client $330K. By misclassifying, PBM B claims to meet the 21% specialty guarantee by combining specialty generic and specialty brand discounts.
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