Field Notes from the Frontline: 3 Pharmacy Pains Payers Can’t Ignore
Over the past few weeks, we’ve been in deep conversations with TPAs, carriers, and self-insured employers—and a pattern has emerged. Everyone’s wrestling with some version of the same headache:
→ GLP-1s sneaking into claims
→ Physician dispensing bypassing oversight
→ And PBM “transparency” that feels anything but clear.
In this week’s P4P, we’re cutting through the noise. No fluff, no spin—just the top 3 pharmacy pain points facing workers’ comp payers right now, and smarter ways to fix them.
Because when the fog clears, so does performance.
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1. GLP-1s Are the Canary in the Coal Mine
Once a whisper, now a roar—GLP-1s like Ozempic and Wegovy are flooding into comp claims, often without supporting documentation, outcomes monitoring, or long-term cost plans. They’re not the only specialty drug making noise—but they’re a warning shot.
✅ The Fix:
Layer in pre-approval checkpoints for high-cost therapies. Build a clinical approval framework that doesn’t just say yes or no—but asks why, when, and for how long. Combine that with longitudinal monitoring to stop passive approvals from becoming long-term liabilities.
2. Physician Dispensing Sidesteps the Playbook
Despite formulary rules and networks, physician dispensing remains a costly loophole. It inflates spend, undermines safeguards, and often escapes audit trails.
✅ The Fix:
Deploy real-time clinical edits with custom business rules—ones that flag physician-dispensed meds automatically for review or rejection. Partner with your PBM to maintain a strict default posture grounded in statute. It’s not about policing—it’s about protecting.
3. Transparency Talk, Vendor Walk
Many payers still don’t know what they’re actually paying for—or where the dollars go. Rebate math is fuzzy. AWP discounts are inflated. “Pass-through” often passes over critical context.
✅ The Fix:
Move beyond buzzwords. Demand line-item clarity on pricing, rebate logic, and service fees. Require MAC list visibility. Push for contracts with auditable definitions—not vague assurances. If a PBM can’t show you exactly how it makes money, you’re the product.
Final Dose
Most of the challenges in workers’ comp pharmacy aren’t unsolvable—they’re just untreated. Payers don’t need a new strategy. They need a true partner who can see the red flags before the bill hits the system and tailor solutions to fit their risk, population, and workflow. That’s what Prodigy was built for.
Better decisions start with better questions.
Let’s ask smarter ones—together.
📞 Let’s talk. If you’re ready to trade volume for value, and autopilot for actual oversight, Prodigy is ready to show you what real care looks like. Call me for a virtual consult. No pressure. Just clarity. I promise—it’ll be worth your while.
About P4P
A Strategic Dose of Clarity in a Noisy PBM Market
Written by Prodigy CEO Del, P4P delivers sharp, consultative insights for decision-makers who are tired of legacy models, hidden costs, and passive vendors. Each piece is a prescription—cutting through the noise to reveal what actually drives performance in pharmacy benefit management.
No fluff. No spin. Just insight that pays off.
