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Your 2026 New-Age PBM Checklist

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Pharmacy benefit management plays a critical role in controlling health insurance costs and improving member health outcomes. But not all PBMs are created equal. The right PBM won’t be just another vendor in your benefit suite but a true partner that has your best interests in mind.  

Pharmacy benefit management is evolving, and so are the expectations of employees and plan sponsors. Rising drug costs, complex rebate structures, and member experience challenges make choosing the right PBM partner more critical than ever. But what does the modern, new-age PBM look like? Here's your checklist for success. 

1. Transparent Pricing & A Modern PBM Model 

PBM models have been under the microscope for some time now. The larger, legacy PBMs that operate on a traditional, spread-based model are no longer the primary option. Instead, modern, alternative PBMs offer a transparent, pass-through model that prioritizes upfront pricing and fee structures.  

Look for a modern PBM that offers clear, auditable contracts and pass-through pricing that puts the plan sponsor in the driver’s seat. You might also consider the age of the PBM; buy-outs, mergers, and acquisitions are common in the PBM market, so it’s best to ensure your prospective PBM has deep-seated roots in the pharmacy space and has no plans to sell.  

2. Data That Delivers 

Data drives decisions and empowers decision-makers like you. Your PBM’s transparency should encompass claims data and performance. As the plan’s sponsor, look for real-time access, actionable reporting, and data dashboards that you can customize to display the metrics most important to you and your team.  

At MedOne, we believe in “your data, your way.” Employers and plan sponsors need real-time insights to make informed decisions. Our technology platforms give you the visibility into the utilization, cost trends, and member engagement you need to take control of your pharmacy spend. But we don't stop at dashboards; our team walks you through the data so you can act with confidence, leveraging all the levers available to you, which brings us to… 

3. Service That Stands Out 

With so many moving parts, your PBM should be accessible to both you and your members. For your member population, Look for a knowledgeable, professional, and accessible customer service center, staffed with industry experts who are equipped to answer any questions your membership may have about their pharmacy benefit. Flexible hours, translation services, chat features are all additional features members appreciate.  

On the HR side of things, the “set it and forget it” mindset doesn’t fit the bill anymore. Your PBM should proactively provide you with insights into your pharmacy spend as well as actionable recommendations for how you can achieve the goals of your benefit philosophy. This can only be achieved with a standard of service that really stands out. Your PBM should be responsive to questions and quick to resolve issues, even outside of regularly scheduled meetings. High-quality service is the new standard.    

4. A Member-First Mentality 

Cost savings matter, but not at the expense of member health. Look for a PBM that prioritizes evidence-based decisions and offers programs to improve adherence and drive positive clinical outcomes. Managing a formulary isn't just about cost; it's about ensuring members have access to 1) safe, effective, and appropriate medications 2) at the best price.  

It's easy to lose sight of the big picture when vetting out vendors, but don’t lose track of your members and the experience they can expect with this PBM; they’re the reason you offer the benefit in the first place! Look for a member-centric and experience-oriented PBM that will deliver satisfaction over frustration. Throughout the entire interaction. 

5. A Culture You Can Trust 

Ready for one of the best tricks of the trade when evaluating your PBM? The measuring stick you can use? Look at the employees who work for this PBM. Are they happy? Do they look forward to coming to work? Are they in it for the right reasons? It might seem unconventional to look into a vendor’s company culture, but it feeds the cycle. If those employees love what they do, they’ll bring that same level of respect and commitment to serving you, their clients.  

A PBM's company culture matters. Choose a PBM whose culture mirrors your own. This makes for an aligned business relationship upon which collaboration, innovation, and partnership can thrive. 

Choosing a PBM partner is one of the most important decisions you'll make for your health plan. Setting the checklists and the pros and cons aside, at the end of the day, your decision should come down to this one thing: Do you trust this PBM partner? Do they do things the right way? Do they keep their word? Would you look forward to working with this PBM day in and day out? Based on how often we’re in touch with our clients, we sure hope so! Answering this one question might just whittle down your prospect list. Once you have this answer, you can then go down your checklist.  

Ready to start checking the boxes?  

Chat with our Sales team to get a feel for what it’s like working with MedOne: sales@medone-rx.com. 

A Better Way to Manage Your DMRs with myMedOne | MedOne News | MedOne - Pharmacy Benefit Solutions
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A Better Way to Manage Your DMRs with myMedOne

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The newest feature of myMedOne is here! The Direct Member Reimbursement (DMR) features are designed to make the reimbursement experience easier, more transparent, and stress-free. Though not the most common, there is sometimes a need to process DMRs. These reimbursements cover situations like when members: 

  • Fill at an out-of-network pharmacy.
  • Have outdated insurance on file at a pharmacy forget to present their ID card. 
  • Choose to pay out-of-pocket for their medication for an early or vacation refill. 
  • Fill a compounded medication. 

If, for whatever reason, a member may pay out of pocket for a prescription that should have been covered on the member’s pharmacy benefit, this new process allows for direct reimbursement for that claim. This ensures the member can access the correct pricing under their plan, keeps everything compliant and accurate for reporting, and helps maintain the trust of the member and their pharmacy benefit.  

Effective January 1, 2026, DMR submission is through the online form available to all members. When a member submits a request using this form, it is automatically added to our DMR tracking system, eliminating the need for MedOne employees to manually input and process the request. Members access the online reimbursement option through their myMedOne portal under the CLAIMS sub menu, labeled REIMBURSEMENT. The only exception to this is compound medications. Given the detailed nature of compounded medications, these requests need to be submitted via paper form and mailed to MedOne. These forms are available upon request. 

Additionally, members can now add multiple claims within a single DMR form, saving time by avoiding the need to submit a separate form for each medication. After the member enters the details for each claim and clicks ADD, the claim information will appear, and an additional + ADD CLAIM button will be available to include more claims. 

For every request submitted, the member is instructed to attach a copy of the pharmacy receipt and the cash register receipt. After uploading the required documents and agreeing to all the terms, the form will be submitted and is immediately accessible to our team. Upon submission, the member will receive an ACCEPTED text or email if they opted in for notifications and will have the option to edit their notification preferences or return to the Reimbursement Center page. During the submission, members must provide a valid contact phone number and email address so MedOne employees can reach out for any additional information that is needed. 

Once requests are submitted, members can access the DMR Status Page in myMedOne. This provides complete visibility into their past and pending requests, allowing members to see the status of their claims in real time, view detailed notes, and see a full list of all submitted claims, all in one place. Plus, members will receive notifications as their claim status changes, so members are always informed without having to repeatedly log in.

These enhancements are designed to make the reimbursement experience easier, more transparent, and stress-free.

MedOne Earns Top Titles at Des Moines Register Top Workplaces Event | MedOne News | MedOne - Pharmacy Benefit Solutions
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MedOne Earns Top Titles at Des Moines Register Top Workplaces Event

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After earning the title of "Best Places to Work in Dubuque" in 2023 and 2024, MedOne Pharmacy Solutions looked beyond the shores of the "Mighty Mississippi" in 2025. 

MedOne was recognized by Iowa Top Workplaces & the Des Moines Register. The announcement event was held at Prairie Meadows Casino in Altoona, IA, on Wednesday, September 24 and welcomed guests from across the state. In attendance were top-performing organizations representing industries from banking and manufacturing to healthcare and PBM, like MedOne. Invitees to the event included other organizations in the top 10% of the over 4,000 participating entities.

The ranked awards for overall top workplaces in the three categories - small, midsize, and large - came later in the night. First to be recognized were organizations exemplifying specific traits. These "special awards" showcased traits like strength in leadership and business direction to training and benefits. 

MedOne received the Well-Being award for “Prioritizing employee well-being,” which is consistent with their #1 Core Value. Coupled with placement in the top ten, MedOne CEO Wes Hartig is humbled and proud of his team: 

When others ask what makes MedOne unique and successful, it’s our people.

Wes Hartig, CEO of MedOne

"Our people deliver outsized value to those we serve and make MedOne a fun and fulfilling place to work through living out our Core Values and recognizing their fellow teammates who do the same. Our people are the heart of this company and this Top Workplace in Iowa award goes to them."

The Top Workplaces awards and recognitions are based solely on employee feedback gathered through a third-party survey administered by employee engagement technology partner Energage, LLC. The confidential survey uniquely measures the employee experience and its component themes, including employees feeling Respected & Supported, Enabled to Grow, and Empowered to Execute, to name a few.

Attendees enjoyed a lively celebration with music from DJ Andy “Cubbie” Powell of Select Entertainment, along with food, drinks, and networking among Iowa’s best employers.

Formulary Management & New-to-Market Medications | MedOne News | MedOne - Pharmacy Benefit Solutions
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Formulary Management & New-to-Market Medications

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P&T Committee Reviews Q2 New-to-Market Drugs

As part of MedOne’s commitment to clinical excellence and cost-effective care, the Formulary Management Sub-Committee of our larger Pharmacy & Therapeutics (P&T) Committee met recently to evaluate newly FDA-approved medications that came to market in Q2. These quarterly meetings determine if and where these new-to-market medications would be placed within our formulary. 

This review process ensures that our clients and members have access to the most appropriate therapies, aligned with both clinical value and financial sustainability.

Outlined below is a sampling of some of the drugs that were reviewed and the corresponding commentary and tier placement. These drugs, while approved by the FDA, have had little time in the market, so it can be difficult to assess their efficacy as well as their financial impact. Therefore, the sub-committee can deploy a “New-to-Market Block.” When placed on a specific drug during review, this delays placement, requiring more data to be present before moving forward. This notation was deployed on the following: 

Tryptyr (acoltremon)

Approved on May 28, 2025, Tryptyr is an ophthalmic solution used to treat the signs and symptoms of dry eye disease. While it introduces a new mechanism of action, the committee opted to place it on formulary as a Non-Preferred Brand with a New-to-Market Block, allowing time to assess comparative effectiveness and member response.

Andembry (garadacimab-gxii)

Approved on June 16, 2025, Andembry is a once-monthly injection treatment designed to prevent attacks of hereditary angioedema (HAE), or painful swelling of the arms, legs, face, throat and abdomen. As an orphan drug, it offers a targeted solution for a rare but serious condition. The committee placed Andembry on formulary as a Non-Preferred Brand Specialty with a New-to-Market Block, allowing time for further evaluation of real-world outcomes and pricing dynamics.

Orphan Drugs

The orphan designation is awarded to drugs by the FDA alongside their approval. Orphan drugs treat rare diseases that affect a small percentage of the population, and there are often few to no treatment alternatives. While demand for these medications is typically low, the need (when it does arise) is urgent. As a result, these treatments tend to be very expensive and can place a significant financial burden on self-funded insurance plans. 

You may be aware that MedOne has an Orphan Drug Exclusion election built into our benefit specification form (BSF). This option to exclude certain orphan drugs allows for the prioritization of other treatments ahead of some of these therapies, protecting plan sponsor resources. Of course, if an orphan drug is deemed the best course of treatment for a member, this is evaluated in our clinical review process and addressed on a case-by-case basis. 

Several orphan drugs were up for discussion during this review session, including those outlined below. 

Avmapki Fakzynja Co-Pack (avutometinib + defactinib)

This combination therapy was approved on May 8, 2025, for the treatment of KRAS-mutated recurrent low-grade serous ovarian cancer (LGSOC) following prior systemic therapy. As an orphan drug, it addresses a niche but critical need in oncology. The committee placed it on formulary as a Non-Preferred Brand Specialty, recognizing its potential while maintaining cost oversight.

Ibtrozi (taletrectinib)

Ibtrozi received FDA approval on June 11, 2025, and is indicated for the treatment of locally advanced or metastatic ROS1-positive non-small cell lung cancer (NSCLC). This once-daily oral therapy is also designated as an orphan drug. Given its clinical relevance and specialized use case, it was added to formulary as a Non-Preferred Brand Specialty.

MedOne’s Formulary Management Approach

These were just four examples of how new-to-market medications can end up on formulary. Each medication is evaluated based on clinical efficacy, safety, cost-effectiveness, and alignment with MedOne’s mission to unlock the most appropriate prescription at the most affordable price. Our P&T Committee includes pharmacists, clinicians, and other intentional representatives who ensure that every formulary decision reflects our commitment to real results, real people, and real savings.

MedOne CEO Shares Stage with Mark Cuban | MedOne News | MedOne - Pharmacy Benefit Solutions
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MedOne CEO Shares Stage with Mark Cuban

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DUBUQUE, July 8, 2025 —  MedOne Pharmacy Benefit Solutions CEO Wes Hartig will share the stage with venture capitalist, businessman, and entrepreneur Mark Cuban. The co-founder of Mark Cuban Cost Plus Drug Company (MCCPDC) will participate in a panel discussion focused on employer solutions for controlling pharmacy costs tomorrow, July 9 at The Mint at Michigan First Conference Center north of Detroit. 

This event is aimed at helping self-funded employers prepare for the largest increases in employee benefit plan costs industry professionals have seen yet. The three key talking points that are slated are: 1) the "new horizon" or era of employer pharmacy cost, 2) aligning the supply chain including and 3) what the presenters are calling "game changer" or infusion & specialty cost containment solutions.

Cuban, through MCCPDC and his many relationships, is changing the game of pharmacy benefits by eliminating the many layers of revenue in employer’s supply chain and creating more transparency in the market.

In MedOne's 2024 Drug Trend Report published earlier this year, Cuban is quoted saying: “By partnering with MedOne, we can get affordable medications to more patients who need them. Healthcare shouldn’t be a black box where drug costs are hidden so that insurance companies can make money off of sick patients and American employers. Cost Plus Drugs is about making quality medications affordable and being transparent with our pricing. The partnership with MedOne aligns with our mission. Together, we’re giving people access to low-cost drugs without any hidden fees or surprises. It’s all about transparency and making a real difference in people’s lives.”

The topic of this event's presentation material is meant to further underline how employers can get the most appropriate prescriptions in the hands of their members at affordable prices, the overall mission of MedOne. 

 

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About MedOne Pharmacy Benefit Solutions

MedOne helps organizations and their health plan members conveniently access the most appropriate prescription at the most affordable price through its aligned and performance-based pharmacy benefit solution. MedOne’s offering focuses on enhancing the member’s pharmacy benefit experience, improving clinical outcomes, and reducing net cost for plan sponsors and their members. MedOne operates in all 50 states, and its customer base includes organizations of all sizes and across a variety of industries. MedOne is honored to be included in the 2024 Inc. Magazine’s 5000 fastest-growing private companies in America. For more information, visit www.medone-rx.com.

From a Pharmacist: Wear Sunscreen | MedOne News | MedOne - Pharmacy Benefit Solutions
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From a Pharmacist: Wear Sunscreen

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Summer is here and in full swing! With it comes ball games, swimming pools, hiking trails, golf courses, and all things outdoors. While it is often encouraged by healthcare professionals to get outside and enjoy some healthy exercise, it is imperative to protect yourself from the sun.  

Sunlight is our body's main source of vitamin D, which is essential for supporting strong bones, a healthy immune system, better mood, heart health, and muscle function. While sun exposure offers these benefits, too much sunlight can be harmful and do more damage than good.  

Sunlight is the primary source of ultraviolet (UV) radiation, a major risk factor for all skin cancers. There are two types of UV radiation that contribute to this risk: UVA and UVB rays. Fortunately, there are many ways to protect ourselves from harmful UV exposure. Effective protection methods include: staying in the shade, wearing long clothing to cover your skin, wearing sunglasses and hats to shield your eyes and face, and applying sunscreen to exposed areas of skin.  

Because both UVA and UVB rays increase the risk of skin cancers, it is important to choose a sunscreen with broad spectrum coverage to protect against both. When selecting a sun protection factor (SPF), the level of protection needed depends on the outdoor activity and how long you will be exposed to the sun. SPF 30 is ideal for everyday wear, while SPF 50 is better for extended outdoor activities such as swimming, outdoor sports, or working outside.  

The idea of all-day sunscreen coverage is a myth! Sunscreen should be reapplied at least every two hours and immediately after sweating or swimming. Even water-resistant sunscreen formulas will wash off eventually. Sunscreens labeled “water-resistant” should be reapplied after 40 minutes in the water, and sunscreens labeled “very water-resistant” should be reapplied after 80 minutes. Regardless of type, all sunscreen should be reapplied after toweling off.  

MedOne encourages everyone to prioritize their well-being. It's one of our Core Values! One great way to do this is by getting outside and enjoying the summer season… just don’t forget to pack your sunscreen!  

 

-Claire H.  
PharmD Candidate 
University of Iowa College of Pharmacy  - Class of 2026 

MedOne Releases 2024 Drug Trend Report | MedOne News | MedOne - Pharmacy Benefit Solutions
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MedOne Releases 2024 Drug Trend Report

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MedOne Releases 2024 Drug Trend Report Focused on Health Outcomes, Lowered Net Cost, and Customer Experience

MedOne Pharmacy Benefit Solutions, a full-service, transparent pharmacy benefit manager (PBM), is proud to announce the release of its inaugural 2024 Drug Trend Report, offering a data-driven, transparent look into the evolving pharmacy benefit landscape. This report includes data and metrics from MedOne's book of business, claims data, and financials, identifying key trends in spend and utilization. Analysis has been conducted and framed using the lens of MedOne's own proprietary scoring system, The MedONE Score, focusing on 1) health outcomes, 2) net cost, and 3) customer experience as it explores 2024 trends. 

“MedOne has established a reputation as the 'best kept secret' in PBM, and now the secret is out,” said Dr. Nate Harold, PharmD, RPh., Chief Pharmacy Officer at MedOne. “For 25 years MedOne has been at the forefront of price transparency, improving outcomes, and providing unmatched customer service. In 1999 we set out to do the right things for the right reasons, and we are excited to show you what happens when those principles guide you."

In 1999 we set out to do the right things for the right reasons, and we are excited to show you what happens when those principles guide you.

Dr. Nate Harold, PharmD, RPh., Chief Pharmacy Officer

The report highlights key trends impacting prescription benefits throughout 2024. Setting the stage as part of the report’s "key insights" is an impressive $67.39 net per member per month (PMPM) spend for 2024; a 0.04% year-over-year increase in prescription spend trend; and a 673% increase in membership since 2018. When compared against industry benchmarks, this result is 43.5% lower than the industry net PMPM spend average.

The report identifies increased utilization of specialty medications, consistent with the rise of new specialty medications approved in the U.S. market. This correlates with an average net PMPM spend of $24.13 in the specialty medications category, which is approximately a 3% decrease year-over-year. New biosimilar and generic options, as well as increased use of cost-plus pharmacies, helped reduce cost while more patients accessed specialty treatments.

MedOne's utilization management strategies can objectively be deemed successful; clinical outcomes are analyzed throughout the report, depicting positive results for patients when measured against nationally accepted benchmarks. For example, 2024 data reflects an improved percentage of members at goal on treatment for chronic conditions like diabetes, rheumatoid arthritis, and multiple sclerosis.

Outlining different cost containment strategies and successes, MedOne's 2024 Drug Trend Report returns to the recurring theme of customer experience, even stating: “If not for our patients, then why would we exist.” Statements of support from clients and members of MedOne benefit plans alike speak to the focus MedOne places on enhanced customer experience. One testimonial is from Phillip Blair, the Vice President of Human Resources at Gamber-Johnson, an organization recognized as the #1 Healthiest Workplace in Wisconsin and the #15 in the United States according to Healthiest Employers®, in partnership with Springbuk. He shares: "Our partnership with MedOne has been instrumental in aligning pharmacy benefit strategies with meaningful health outcomes. By leveraging MedOne’s integrated solutions and proactive approach, we’re not just managing costs—we’re making strategic investments that truly improve the health and well-being of our members.”

Several instances in which members were given the opportunity to provide feedback on their experience with MedOne are represented in the report. With concerted effort to measure and enhance the member experience, MedOne has achieved a 4.6/5 Google rating and 4.8/5 member satisfaction score based on internal survey results.

In addition to the key trends detailed in the report, MedOne outlines additional market changes that have had a significant impact on the prescription benefit landscape. The report concludes with a look-ahead commentary on what the anticipated drug trends are set to impact plans in the coming year.

 

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About MedOne Pharmacy Benefit Solutions

MedOne helps organizations and their health plan members conveniently access the most appropriate prescription at the most affordable price through its aligned and performance-based pharmacy benefit solution. MedOne’s offering focuses on enhancing the member’s pharmacy benefit experience, improving clinical outcomes, and reducing net cost for plan sponsors and their members. MedOne operates in all 50 states, and its customer base includes organizations of all sizes and across a variety of industries. MedOne is honored to be included in the 2024 Inc. Magazine’s 5000 fastest-growing private companies in America. For more information, visit www.medone-rx.com.

5 Trends for PBM in 2025 | MedOne News | MedOne - Pharmacy Benefit Solutions
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5 Trends for PBM in 2025

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The pharmacy benefit landscape is evolving rapidly, and 2025 is proving to be a pivotal year. Rising drug costs, increased demand for transparency, and the emergence of new therapies are pushing plan sponsors to rethink how they manage their pharmacy benefit. At MedOne, we’ve identified the following five key trends that are reshaping the PBM space and what they mean for your organization. 

1. Active Management: The End of “Set It & Forget It”

Gone are the days when pharmacy benefits could be placed on autopilot. Today’s environment demands a hands-on, data-driven approach. Plan sponsors must work closely with their brokers and PBMs to continuously evaluate claims data, identify cost drivers, and implement strategies that align with their organizational goals. 

This doesn’t mean a one-size-fits-all solution. Every organization has unique needs, and success depends on tailoring benefit strategies accordingly. Whether it’s adjusting formulary design, implementing utilization management tools, or exploring alternative funding models, proactive management is essential for long-term sustainability. 

2. Visibility & Transparency: Your Data, Your Way

The foundation of any effective pharmacy benefit strategy is access to data. Without it, plan sponsors are flying blind. That’s why “transparency” is more than a buzzword. It’s a necessity. 

At MedOne, we believe in “Your Data, Your Way.” Plan sponsors should have full access to their claims data in formats that are easy to analyze and act upon. But transparency doesn’t stop at data access. Understanding how your PBM earns revenue—whether through spread pricing, rebate retention, or other mechanisms—is critical. These financial incentives can influence formulary decisions and ultimately impact member health outcomes. 

The goal? Align PBM incentives with what truly matters: better health outcomes, lower net costs, and a high-touch, high quality member experience. 

3. GLP-1 Strategy: Balancing Access & Oversight

GLP-1 medications, originally developed for diabetes, have surged in popularity due to their effectiveness in weight management. But with high demand comes high cost, and plan sponsors are feeling the pressure. 

Most PBMs now require prior authorization (PA) for GLP-1s, but not all criteria is created equal. It’s vital to understand how these drugs are being covered and why they’re driving spend. If your plan covers GLP-1s for weight loss, consider pairing that coverage with a wellness program. MedOne partners with Tria Health to ensure members are set up for long-term success. These medications are most effective when combined with routine changes, member support, nutritional counseling, and lifestyle coaching. 

4. Biosimilars: A New Era of Savings

The biosimilar market is gaining momentum, and 2025 is a breakout year. With blockbuster drugs like Humira and Stelara losing patent protection, plan sponsors have a golden opportunity to reduce costs through the use of biosimilars.  

New-to-market medications like Yusimry and Otulfi offer lower net costs without compromising clinical outcomes. But success depends on agility. PBMs must be able to pivot quickly, update formularies, and guide members through transitions seamlessly. 

At MedOne, we take a hands-on approach to biosimilar adoption, ensuring a smooth member experience that prioritizes maximum savings. And with more high-cost drugs set to go off-patent, this trend is just beginning. 

5. Net Cost Focus: Looking Beyond the Rebate

Rebates have long been a focal point in pharmacy benefit discussions, but they don’t tell the whole story. A high rebate on an overpriced drug isn’t a win if that drug shouldn’t have been on the plan in the first place. 

That’s why we encourage plan sponsors to focus on net cost, the true bottom line after accounting for discounts, rebates, and administrative fees. A net cost approach ensures every dollar is spent wisely, avoiding short-term illusions of savings and promoting long-term plan sustainability. 

2025 is a year of transformation in PBM. From embracing biosimilars to rethinking GLP-1 coverage, plan sponsors have more tools—and more responsibility—than ever before. The common thread across all five trends? Intentionality. Success in today’s pharmacy benefit landscape requires active engagement, transparency, and a relentless focus on value. 

At MedOne, we’re here to help you navigate this evolving landscape with clarity and confidence. Talk with a member of our team to learn more: info@medone-rx.com.  

Proposed Changes to the PBM Landscape: The MedOne Take | MedOne News | MedOne - Pharmacy Benefit Solutions
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Proposed Changes to the PBM Landscape: The MedOne Take

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The regulatory landscape of pharmacy benefits is hot with activity. When asked about our views on PBM reform and whether we are for or against it, we assess from the viewpoint of whether it is good for: 1) the public, 2) plan sponsors, and 3) MedOne.  

There are two primary happenings MedOne is closely following: SF 383 (the Iowa PBM) bill currently under review by Governor Reynolds and the Executive Order released from the White House earlier this week titled “Delivering Most-Favored-Nation Prescription Drug Pricing To American Patients.” 

Here’s what you need to know: 

SF 383 (Iowa PBM) Bill:

Iowa’s PBM reform bill, heavily backed by the Iowa Pharmacy Association, targets and aims to combat discriminatory PBM practices, restore patient choice, and enforce adequate reimbursement to Iowa pharmacies.  

In general, MedOne is supportive of this bill as it bans spread pricing and requires 100% pass-through pricing of discounts and rebates. This bill also requires that retail pharmacies are paid a minimum reimbursement of NADAC (publicly available benchmark reflecting the average pharmacy’s acquisition cost for drugs) + a $10.68 dispense fee. Many competitors critique this provision, indicating it will lead to an increase in cost for Iowans and Iowa employers.  

When we look at our data, we see a very different picture and are not concerned; it instead showcases a win-win-win: Lower prices for Iowans and our clients, better reimbursement for independent pharmacies, and neutral to MedOne since we don’t generate revenue based on what we reimburse pharmacies. 

While we may not fully support each element of SF 383 (we view requiring copay coupons to track toward deductibles and out-of-pocket maximums as a negative for our clients), this bill is a step in the right direction, and MedOne is ready to help Iowa employers navigate and embrace this positive change.  

Regarding the Executive Order (EO):

The general goal of the EO is ensure pharmaceutical manufacturers are offering a “most-favored-nation price” to Americans; in other words, as good as the lowest price offered in any other country, which is not the case today. The opening lines of the EO state: "The United States has less than five percent of the world’s population and yet funds around three-quarters of global pharmaceutical profits." Going on to describe this as "egregious," as the U.S. as an "unwitting sponsor," and this practice as a whole as "abuse of the Americans' generosity." This sets the stage for a targeted and toothy path forward.  

It appears many of the action items emerging from this order will fall to the Health and Human Services Secretary as the primary lead. Tasked with communicating the most-favored-nation price targets to pharmaceutical manufacturers within 30 days of May 12, we look forward to seeing these targets take shape.  

Should this prove unattainable, the Secretary is then tasked with proposing rulemaking that would (make it mandatory, not voluntary to) formally allow drug importation from developed nations with low-cost prescriptions, and/or other steps to penalize noncompliance. We expect pharmaceutical manufacturers to push back, but it is worth noting that this EO gives the Administration a path forward (in addition to significant threats). We are optimistic as it seems this effort is intended to address all Americans (not just Medicare and Medicaid programs) and would lead to lower net prices for our clients and members, alongside broader access with more pricing parity and greater simplicity for the average American. 

At this point in time, regarding both cases, we wait and we hope for more  transparent and affordable prescription drug prices for all. 

MedOne’s continued focus for our clients and members:

For over 25 years, MedOne has charged transparent fees for our services that we must (and do) justify in how we help our clients manage spend, care for their members, and deliver quality service. Our business model is incredibly simple, yet effective: 

   ▪️   Charge a transparent, aligned Per Member Per Month (PMPM) administrative fee where our revenue is not driven by increasing spend. 

   ▪️   Ensure appropriate use of prescriptions so you “pay for the right things" opposed to “pay for everything” or “pay for nothing.” 

   ▪️   Extend our single and best price for prescriptions to ALL clients without adjustment, while embracing innovators who can deliver even lower prices. 

   ▪️   Support members in their journey to conveniently access the most appropriate prescription at the most affordable price. 

Our business model has delivered proven results for our clients and is well-positioned for continued change across the pharmacy landscape. In fact, we welcome these types of changes when they benefit our members and clients. 

We will continue to monitor the regulatory landscape and provide material updates as they are available. If you have any questions, please contact your Account Manager.

MMR Vaccine | MedOne News | MedOne - Pharmacy Benefit Solutions
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MMR Vaccine

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1,024 cases of measles have been confirmed in the US as of May 15, 2025. Given this rise, we’ve fielded lots of questions about the virus and the Measles, Mumps and Rubella (MMR) vaccine. Let’s dig into this topic a bit further!

We’ll first start with the confirmed cases, the cases are equally spread amongst all age groups (under 5 years of age, 5-19 years of age, and 20 years and older), with the majority of the cases, 97%, reporting either an unvaccinated or unknown vaccination status. Out of all the cases, there is only one confirmed death and 1 other under investigation. It’s important to keep in mind that the US currently has 340.1 million people, so 607 confirmed cases are less than 1% of the population. 

Measles is a high contagious viral illness that starts with a fever, cough, fatigue and runny nose, within 7-14 days after exposure small white spots with bluish-white centers will appear inside the mouth on the cheek. These are called Koplik’s Spots. People who suspect they have been exposed to the measles should contact their healthcare provider or an urgent care center immediately for care. 

In 1963 the first measles vaccine was licensed for use in the US and was the first significant step in measles protection. Patients who were born before 1957 are generally considered to have a natural immunity to measles as most children contracted it and have formed a life-long immunity to it before that time.  In 1989, an outbreak of the measles among school-aged children prompted a recommendation for a second dose of MMR vaccine for all children, which led to a further decline in reported cases, with the US declaring an elimination of measles in 2000 (an absence of the continuous spread for greater than 12 months). 

The MMR vaccine is currently recommended to be given 2 doses of the vaccine with the first dose between the age of 12-15 months, and the second dose between 4 and 6 years old. Older children, adolescents and adults should only receive additional doses of the MMR if they do not have evidence of immunity. This evidence would be in the form of a laboratory titer test. Titer tests are blood tests that check for the presence of antibodies which indicate immunity to, in this case, the measles. This immunity can be either from a vaccination or from a past infection. 

The CDC further explains that only people at increased risk during an outbreak should receive an additional dose of the MMR, and those people will be notified by public health authorities. 

Further take aways include that no booster vaccine is recommended at this time, with the CDC stating that “people who received two doses of measles vaccine as children according to the U.S. vaccination schedule protected for life, and they do not ever need a booster dose”. 

Finally, remember that good hand hygiene, staying home when sick, cleaning surfaces regularly, and overall good nutrition and rest can help keep you safe from any virus, including measles, mumps, and rubella! 

The MedOne Biosimilar Strategy: Stelara® | MedOne News | MedOne - Pharmacy Benefit Solutions
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The MedOne Biosimilar Strategy: Stelara®

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MedOne is excited to announce the newest iteration of our Biosimilar Strategy! Effective April 4, 2025, MedOne will be preferring Otulfi®, as it is the lowest net cost biosimilar for the reference product Stelara.

This change is set to bring substantial savings, reducing costs by an impressive 96% (when compared to the list price of Stelara) for our clients and members who have been previously utilizing Stelara to treat Crohn's disease, ulcerative colitis, plaque psoriasis, or psoriatic arthritis. 

Through our partnership with ​Mark Cuban Cost Plus Drug Company (MCCPDC), the cost of treatment using Otulfi will be between $4,000-6,000 annually compared to other treatments that cost $40,000+ annually. 

Strategy Details


This shift will operate similarly to our Humira-to-Yusimry iteration of the Biosimilar Strategy. Otulfi will be placed on our T0 specialty list, like Yusimry, allowing plans that exclude specialty medications access to this cost-effective biosimilar.

Stelara will be removed from the PAP-eligible list. This change comes as Johnson & Johnson (J&J) has removed Stelara from their list of eligible drugs for manufacturer assistance. Current members utilizing the J&J Foundation will continue to access Stelara through the Foundation until no longer eligible. Upon notification that a member no longer is accessing Stelara through the J&J Foundation, the member will be transitioned to Otulfi and fill at MCCPDC. 

Like Yusimry, indication-based exclusions will still apply. 

Effective immediately, Stelara will no longer be included in our international sourcing program. The price to access Brand Stelara internationally exceeds the cost to fill Otulfi at Cost-Plus Drugs. The PCC team will work to transition patients to filling Otulfi domestically.  

All-in-all, this iteration of our biosimilar strategy supports our overall mission: To provide members with access to the most appropriate prescription at the most affordable cost.

About Biosimilars

Biosimilars are a type of biologic medication that are safe and effective. Biosimilars are medications aimed to replicate the therapeutic safety and efficacy of medications already licensed in the market, which are termed as “reference products” by the Food and Drug Administration (FDA). When biosimilars are considered for market approval by the FDA, the main ingredient structure must be identical to the reference product, but the inactive ingredients (or “excipients”) may differ.

Because of this requirement, a biosimilar and its original biologic have the same treatment benefits and risks. They must also: 

  • Be administered in the same way
  • Have the same strength and dosage form
  • Have the same potential side effects

Because biosimilars are developed by different manufacturers from the manufacturer who produces the reference product, the result is competitive pricing of these already high-cost biologic medications, thus increasing access and coverage affordability for patients and payors. All the while, maintaining clinically effective treatments.

If you have any questions about biosimilars, the newest iteration of this strategy, or anything else relating to your pharmacy benefit, please reach out to your MedOne Account Team. 

The Shifting Tide of GLP-1s | MedOne News | MedOne - Pharmacy Benefit Solutions
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The Shifting Tide of GLP-1s

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The drug class that's taking the world by storm is finally seeing generic alternatives enter the market. From their high costs to their weight loss effects, GLP-1s seem to be what everyone is talking about. And a shift in tide – and price tags – is upon us. 

In December of 2024, the FDA approved the first generic GLP-1, a version of Victoza® (liraglutide injection) for treating type 2 diabetes ages 10 and older. While GLP-1s rose in popularity due to their weight loss effects, this medication, and several others in this class are approved exclusively for the treatment of diabetes, a disease that affects over 11% of the US population. This means high costs for appropriate treatments for our members. Until now. 

“With the accessibility of generic liraglutide, MedOne members will have access to efficacious medication for the treatment of Type 2 Diabetes Mellitus at a lower cost, which could remove financial barriers to care for patients,” said Dr. Katrina Morgan, Director of Clinical Review.

With the accessibility of generic liraglutide, MedOne members will have access to efficacious medication for the treatment of Type 2 Diabetes Mellitus at a lower cost, which could remove financial barriers to care for patients.

Dr. Katrina Morgan, Director of Clinical Review

The availability of generic liraglutide will help drive down costs by reducing total spend on medications, in this case specifically in the GLP-1 receptor agonist bucket. Currently, GLP-1s indicated for the treatment of type 2 diabetes contribute to over 16% of total spend across the MedOne book of business. With generic prescriptions accounting for 90% of prescriptions filled but only 17.5% of prescription drug spend (2023 U.S. Generic & Biosimilar Medicines Savings Report complied by IQVIA), this could add up to major savings for payors.

A generic drug is a medication that is identical to a brand-name drug in terms of active ingredient, strength, dosage form, and route of administration. Brand drugs generally hold a patent for 20 years, which prohibits other companies from manufacturing and selling generics of the medication until the patent is lifted. Generic medications generally are less expensive than brand-name drugs because they do not require the same research and marketing costs. Generic drugs are manufactured to the same quality standards as brand-name drugs and must undergo rigorous testing to ensure their safety and effectiveness. While generic drugs have the same active ingredient, they may have different inactive ingredients, such as fillers, colors, or preservatives. However, this does not affect the therapeutic effect of the drug.

MedOne has been closely watching the development and availability of generic liraglutide and other research in this space. As additional organizations begin to manufacture generics like this, we anticipate significant changes in price. If and when this generic becomes the lowest net cost option, MedOne will announce corresponding formulary changes. 

MedOne and Brightn Launch Innovative Partnership to Address Growing Mental Health Crisis in Iowa | MedOne News | MedOne - Pharmacy Benefit Solutions
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MedOne and Brightn Launch Innovative Partnership to Address Growing Mental Health Crisis in Iowa

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With the mental health challenges today's workforce faces on the rise, MedOne has partnered with Brightn to provide comprehensive mental wellness support for employees and their families across their book of business. This strategic alliance comes at a crucial time, as recent data shows 77% of U.S. workers report experiencing at least one symptom of a mental health condition, with 84% citing workplace conditions as a contributing factor.

MedOne’s clinical team has kept a close eye on this growing mental health crisis as it relates to the pharmacy claims MedOne process on behalf of their self-funded employer groups. Senior Clinical Program Manager Shelby Jones saw the need for additional support for MedOne's members and began the search for an innovative partner in the space to pioneer the Behavioral Care Path offering. 

“Mental health is very important to me,” said Jones. “This offering is the perfect complement to our program supporting mental health wellness. I’ve always been an advocate for mental health services, and I’m excited to bring this unique approach to MedOne’s members.”

Plan sponsors can elect to offer the Behavioral Care Path program. Once elected, there is a two-pronged approach designed to support patients who are seeking support for mental health disorders. 

This first part of the Behavioral Care Path targets members on medications for mental health and ensures those prescriptions are the right medication for that specific member and the state of their mental health. 

MedOne's processes use historical claims data to identify a variety of drug-therapy problems and care plans in order to help members reach their mental health care goals as quickly as possible. Drug-drug interactions, duplications of therapy, and medication non-compliance are common amongst mental health treatments. This care path identifies these disruptions in the treatment plan, and recommendations are sent to prescribers to reduce the serious risk of adverse events. Most mental health medications take 8-12 weeks to demonstrate full effectiveness and patients often have to try 3-4 medications before achieving results. The goal is to get the right medication in the hands of our members as quickly as possible so they can be at their best. 

The second part of Behavioral Care Path targets members who struggle or otherwise want to improve or prioritize their mental health and well-being. Enter Brightn. 

"Recent Harvard studies show that 88% of Americans are metabolically unhealthy, 75% lack clear meaning and purpose, and 77% live paycheck to paycheck," said Jeffrey Johnston, CEO and Founder of Brightn. “These interconnected challenges led us to develop a comprehensive approach focusing on health, wealth, and purpose. After losing both my son and wife to mental health-related struggles, I understand firsthand the critical importance of preventative mental wellness support."

Our goal is to empower individuals to transform their mental health and build a brighter future.

Jeffrey Johnston, CEO & Founder of Brightn

Brightn's approach is to make weekly mental health planning straightforward and effective, helping patients integrate lifestyle improvements seamlessly into their daily life. Through the AI-powered app, customized programming is designed to enhance mental wellness through personalized challenges, mood tracking, and journaling. Access to the app and all its features, progress tracking, and community and peer support are all accessible to MedOne members through the Behavioral Care Path. 

MedOne's own employees and their families are among the pilot participants who are testing the care path offering. These members will receive free access to Brightn's premium platform, which has demonstrated remarkable results - 60% of users report significant improvements in their wellness outcomes after just 30 days of consistent engagement.

"One in eight people globally have a mental health disorder, which means everyone on our team likely knows someone affected by mental health challenges," said Wes Hartig, CEO at MedOne. "As an employer, we want to be proactive in supporting our employees' well-being - it's our number one core value. This partnership with Brightn aligns perfectly with our commitment to supporting the full picture of well-being: physical, mental, and spiritual."

The partnership represents a significant advancement in corporate mental wellness support, combining MedOne's healthcare expertise with Brightn's innovative technology. Both organizations share Iowa roots and Midwest values, creating a strong foundation for this collaborative effort to support local communities.

"This partnership exemplifies MedOne's commitment to innovative healthcare solutions," added Hartig. "Working with a fellow Iowa-based company allows us to be responsive to our employees' needs while supporting local innovation in healthcare technology."

About Brightn

Founded in Cedar Rapids, Iowa, Brightn is transforming mental wellness support through AI-powered technology and personalized planning. The platform focuses on making mental wellness as routine as brushing your teeth, helping users achieve balance in health, wealth, and purpose. Early results show that members who engage with the platform for more than 30 days experience a 60% increase in positive outcomes through the platform's comprehensive tracking metrics. Download the Brightn app today by visiting www.brightn.app

Media contacts:

Emilie Mauricio
Emilie@brightnapp.com

Expedited Access to Stelara® Biosimilars for MedOne Members | MedOne News | MedOne - Pharmacy Benefit Solutions
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Expedited Access to Stelara® Biosimilars for MedOne Members

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MedOne Pharmacy Benefit Solutions, a full-service pharmacy benefit manager, has put parameters in place to grant access to newly approved biosimilars as soon as they come to market. 

The much-anticipated biosimilars for ustekinumab, commonly known by its brand name Stelara®, are set to hit the market in mid-2025. True to MedOne’s commitment to ensuring access for their members to the most appropriate prescription at the most affordable cost, MedOne has added four low-WAC biosimilars to its formulary.

Our clients and patients do not have to wait months, or even years, to use these new cost-effective alternatives, "

said Chief Pharmacy Officer Dr. Nathan Harold.

Dr. Harold goes on to say, "Since MedOne manages their formularies in-house, we are able to do something few can; we added low-cost Stelara biosimilars to formulary, and these will be available to patients as soon as they are stocked in pharmacies.”

The four biosimilars that have been added to formulary at the time of publication are Otulfi, Steqeyma, Yesintek, and Wezlana, the lowest of which coming in at a price point 90% less than the currently available brand name medication.

“The most exciting part is as cost comes down, we are able to better ensure more access to care which will improve clinical outcomes while being the best possible steward of our clients’ financial resources,” said Dr. Harold. This medication is commonly prescribed for Crohn's disease, ulcerative colitis, plaque psoriasis, and psoriatic arthritis, disease states which collectively affect 10.1 million Americans. 

To date, MedOne’s biosimilar strategy has delivered a 90%+ conversion rate to the lowest net cost biosimilar. This newest iteration of this strategy expects to deliver similar results for our clients and members.

From Core Values to Cost Savings: A look at how MedOne cut pharmacy spend in half for Midwest manufacturer | MedOne News | MedOne - Pharmacy Benefit Solutions
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From Core Values to Cost Savings: A look at how MedOne cut pharmacy spend in half for Midwest manufacturer

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From Core Values to Cost Savings

A look at how MedOne cut pharmacy spend in half for Midwest manufacturer. Below is an overview, followed by an explanation of how MedOne successfully overcame the challenges.

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Introduction

Gamber-Johnson, a leading manufacturer of rugged mounting systems, faced significant challenges managing and controlling their pharmacy spend. Rising specialty drug costs, inflexible programs, and limited collaboration with their pharmacy benefit manager (PBM) were driving up expenses while frustrating their team and members.

They turned to their broker partner M3 Insurance, a Midwest-based top insurance broker and risk management firm in search of a solution. At the recommendation of their M3 representative, Gamber-Johnson partnered with MedOne—a full-service pharmacy benefit manager focused on transparency, innovation, and actionable cost containment strategies. This partnership not only met but exceeded expectations, delivering substantial cost savings, improved member outcomes, and unparalleled customer service.

Since making the move to MedOne, Gamber-Johnson was named the #1 Healthiest Workplace in Wisconsin and the #15 in the United States according to Healthiest Employers®, in partnership with Springbuk.

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Before transitioning to MedOne, Gamber-Johnson encountered numerous roadblocks that hindered cost management and member satisfaction. These included: 1) formulary misalignment, 2) inflexibility and lack of innovation, and 3) high specialty drug costs. Phillip Blair, the vice president of human resources at Gamber-Johnson, noticed these patterns in the claims data and grew frustrated with the lack of actionable solutions.

Formulary Misalignment

For Gamber-Johnson, the previous PBM’s approach to formulary management often favored more expensive products, resulting in unnecessary spending.

“When we ran into some with the change in formulary… we would take a look at what the preferred medication with MedOne was versus the preferred medication with [the previous PBM], and they obviously had different methodologies,” said Blair.

Gamber-Johnson found that, when comparing the formularies of MedOne and their previous PBM, the previous PBM’s formulary contained higher-cost medications, often accompanied by high rebates. Based on the traditional model on which the previous PBM operated, these rebates were then retained by that PBM whereas with MedOne’s pass-through model, those rebates would have been routed to Gamber-Johnson. Not only was Gamber-Johnson paying more for on-formulary drugs, they were not awarded the rebates they earned, based on their utilization.

High Specialty Drug Costs

Specialty medications are a rapidly growing category of spend, driving overall prescription spend upwards. The presence of specialty drugs in a claims file is not an issue on its own; the high costs often associated with them, however, is where issues arise. Gamber-Johnson’s utilization featured a handful of specialty claims that were burdening the plan.

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When Gamber-Johnson met with MedOne, it became clear that MedOne’s approach aligned seamlessly with their goals. MedOne’s pass-through and fully-transparent model, combined with a focus on proprietary and actional cost containment strategies, appealed to Gamber-Johnson’s objectives.

Mindy Peterson, a business insurance associate at M3 and lead point of contact for Gamber-Johnson, described MedOne as “proactive, transparent, and member-centered.” Administering a pharmacy benefit is more than dollars and cents. She spoke about her decision to bring MedOne into the conversation: “Knowing what Phil wanted to do and what the future strategy looked like, the core values really aligned; it was a great fit.”

When MedOne speaks about alignment, the conversation goes beyond the world of pharmacy spend. True alignment goes deeper, into the mission, vision, and values of an organization. MedOne for example believes in helping people access the most appropriate prescription at the most affordable price, and core values include 1) prioritizing the well-being of employees, 2) striving to exceed client expectations, and 3) creating and embracing positive change. Pairing up with Gamber-Johnson, the synergy is obvious.

The guiding principles at Gamber-Johnson speak to the importance of generating “joyful growth.” This concept prioritizes the people at the heart of Gamber-Johnson alongside the importance they place on innovative products and operating under impeccable standards. This shared vision spoke to both the M3 and Gamber-Johnson teams, and ultimately invited MedOne to the table.

MedOne met with Gamber-Johnson in the fall of 2023 to discuss a new pharmacy benefit strategy. After sharing about MedOne’s roots in pharmacy and their unique approach to the marketplace, the conversation turned to the pain points Blair and his team were experiencing with the incumbent PBM. This initial touchpoint hammered out the cost-containment & access strategies MedOne would later implement for Gamber-Johnson, outlining MedOne’s depth and expertise. Blair recalled: “The level of conversation was way more than any conversation we had with the previous PBM… We walked out of that meeting and said, ‘Yes, we can move forward.’”

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MedOne’s customer service stood out from the start. Gamber-Johnson’s account is serviced by Chief Pharmacy Officer Dr. Nathan Harold, Director of Account Management Danielle Barton, and Senior Account Manager Whitley Johll. This three-pronged service approach ensures MedOne clients have access to the resources and expertise they need around the clock.  Early in the relationship, Blair recalled that “Danielle and Whitley were phenomenal. They answered every question I had really, really quickly.“

MedOne’s commitment to transparency and proactive service has been key to Gamber-Johnson’s success. MedOne regularly dialogues with both the Gamber-Johnson and the M3 teams sharing insight on up-and-coming industry trends, legislation changes, new cost-saving programs or opportunities, and other relevant topics.

“We’re talking to the MedOne team all the time. When member issues pop up, whether we need to switch drugs or whatever the case may be, it is a partnership.”

At the core, it is about making sure that the member is taken care of versus what kickbacks they’re going to get at the end of the day,”

said Peterson.

For example, a new Gamber-Johnson employee approached Blair expressing an interest in enrolling in the Gamber-Johnson plan but also a concern about a costly medication the employee was on. Blair relayed this information to MedOne to see how the prescription would be handled on the plan.

MedOne ran some test claims and relayed their findings to the Gamber-Johnson team. Per the plan design, the medication in question would not be covered but MedOne provides some additional options the member could explore to obtain their medication. The ensuing conversation was an overall positive one, due to MedOne’s transparent and proactive approach. The member ultimately made the decision to stay on the spouse’s plan. “A new hire hearing their medication was not going to be covered has the potential to be a really hard conversation. We gave them so much information and several different routes they could go down if they were to come to us, and they were happy.”

Consistent and thorough collaboration is key in these situations, and MedOne ensures frequent touchpoints to address questions and provide solutions.

Financial Alignment

MedOne focuses on driving to the lowest net cost for both the plan and the member while maintaining a high standard of care. A large sticking point with the previous PBM revolved around formulary structure and their capture of rebates.

This misalignment in formulary structure can be explained by looking at blood glucose monitoring systems for diabetics. These systems are often viewed as a black-and-white example in pharmacy; the system is either reading the levels and providing an accurate result or not.

The previously preferred monitoring device was a brand-name system costing between $8,252.20-$8,832.20 annually. As this was the preferred system on the previous plan, this drove costs for both the Gamber-Johnson plans and members up, compared to more affordable alternatives like MedOne’s preferred option.

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In this apples-to-apples comparison, MedOne’s preferred system is 2-3 times less than the previous PBM’s. Even with just a small number of claimants utilizing a blood-glucose monitor, the switch to MedOne’s preferred monitor would result in significant savings. The next step was simply to notify members of the upcoming change.

Diabetic members of the Gamber-Johnson prescription health plan were alerted via letter that the new plan, effective January 1, 2024, included a different preferred monitoring system. Disruption is to be expected when making any sort of plan change. It was the proactive communication that ensured a smooth transition of the members to the new device.

“Despite having a pretty drastic change from our previous PBM with a very large formulary – and we still have a very large formulary today – I think we have gotten equal if not better reviews with MedOne,” said Blair.

Innovative Programs

“When meeting with MedOne, what stood out to me was the fact that MedOne has so many of the levers, if not all of the levers, available within their existing structure. We didn’t have to go out and piecemeal all these different things to make an ultimate, better benefit for our team members.”

MedOne’s specialty cost containment strategies delivered dramatic savings for Gamber-Johnson upon implementation. Major pain points with the previous PBM centered on a small number of specialty claims. Knowing this, MedOne encouraged Gamber-Johnson to enroll in MedOne’s RxAlly program, their proprietary suite of specialty cost containment solutions.

While reviewing the claims experience, MedOne’s team of Patient Care Coordinators identified which of the strategies would result in the most savings for Gamber-Johnson and their members.

A handful of members were identified. One of the claims was for a medically necessary brand-name medication for Crohn’s disease. MedOne identified this prescription would be more affordable for both the plan and the member when sourced internationally.

Per the plan’s PPO plan, this member is able to access the medication at a $0 copay. Despite there being no member cost share, the plan still comes out ahead and still captures the rebate per MedOne’s pass-through model. Overall, by leveraging MedOne’s network of international pharmacies, the plan is saving almost $84,000 annually, on this one member alone.

The use of these targeted strategies and upfront communication was the key to such a significant decrease in overall pharmacy spend for the plan.

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Since entering into the partnership with MedOne, Gamber-Johnson has experienced the following savings:

Annual pharmacy spend prior to moving to MedOne was roughly $326,000. It is now in the ballpark $222,000. This moves the per-member-per-month (PMPM) costs from $103 PMPM to $46 PMPM.

It’s important to note, too, that these savings are in spite of an uptick in member count; Membership increased from 264 to 384 members during the first year of the service agreement with MedOne, yet total spend still dropped by over $100,000.

At the end of 2024, Gamber-Johnson spent:

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MedOne’s proactive management and innovative solutions ensured members received the medications they needed while identifying opportunities for cost savings.

Blair and his team experienced open, ongoing communication with MedOne, ensuring alignment on benefit strategies and rapid resolution of issues. “Everything is answered within 24 hours. I have all the information I need,” said Blair.

Conclusion

MedOne’s partnership with Gamber-Johnson exemplifies the value of a proactive, aligned transparent, and flexible PBM. By aligning on core values and implementing strategies tailored to Gamber-Johnson’s needs, MedOne delivers a significant net cost reduction, improved health outcomes, and a level of service unmatched in the industry.

Gamber-Johnson’s success demonstrates that MedOne is more than just a PBM—it is a strategic, key partner in achieving sustainable, member-centered pharmacy benefit solutions.

MedOne Promotes Dr. Nathan Harold to Chief Pharmacy Officer | MedOne News | MedOne - Pharmacy Benefit Solutions
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MedOne Promotes Dr. Nathan Harold to Chief Pharmacy Officer

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MedOne Pharmacy Benefit Solutions, a full-service pharmacy benefit manager, is pleased to announce the promotion of Dr. Nathan (Nate) Harold to Chief Pharmacy Officer (CPO). 

"For over a decade, Nate Harold has been a cornerstone of MedOne's remarkable journey," said Wes Hartig, CEO of MedOne. 

His leadership and relentless drive for improvement has propelled our growth and success."

Wes Hartig, CEO of MedOne

With over 15 years of experience in the pharmacy and healthcare industry, Dr. Harold brings a wealth of knowledge and a forward-thinking approach to his new role as Chief Pharmacy Officer. Dr. Harold will continue to oversee all Clinical and Pharmacy Services, as well as Strategic Pricing moving forward. His experience in growing and leading teams as well as his unique leadership approach will no doubt contribute to the continued overall growth of MedOne. 

Dr. Harold joined MedOne on June 23, 2014 as MedOne’s first Clinical Pharmacy Manager. He was soon thereafter promoted to VP of Clinical Services where, in his tenure, he spearheaded numerous initiatives that have elevated MedOne’s service offerings. His largest to-date is the construction of what is now an 18-program Clinical Care Path Suite. This suite of clinical solutions forms the foundation of MedOne’s benefit plans and corresponding savings strategies, enabling clients to save upwards of 25% on their pharmacy benefits while ensuring quality care and access to appropriate treatments. 

Additional notable accomplishments include: 1) Creating and formalizing a suite of specialty cost containment and access solutions under the sub-brand "RxAlly" designed to help MedOne members gain access to high-cost medications, 2) delivering actionable clinical insights and recommendations to optimize prescription benefit plans and reduce overall spend while ensuring positive clinical outcomes, and finally 3) driving innovation through the integration of cutting-edge technologies to improve data delivery through the use of Macros, bots, AI, and other technologies not often associated with PBM.

Within the Clinical Program Suite lies one of MedOne’s most impactful programs: Opioid Care Path. This is a risk stratification and mitigation program in which MedOne is able to identify members taking opiate products and evaluate risk across five different parameters. If patients deviate and start showing behaviors that can indicate abuse and addiction, MedOne is able to intervene more quickly to change the dynamic to steer members onto a better path. Amid the nationwide opioid epidemic, MedOne is proud to offer such an impactful program. 

In addition to his clinical contributions, Dr. Harold has been a driving force behind the creation and growth of MedOne Pharmacy Services, the company’s on-site mail order and specialty pharmacy. He holds 32 state licenses and has secured strategic partnerships to enable shipments to members in all 50 states. 

"In a rapidly evolving industry, Nate's curiosity and determination to find better solutions consistently elevate our offering. As Nate steps into his new role as Chief Pharmacy Officer, I am excited to see the innovative solutions he will bring to all those we serve. His vision and dedication will undoubtedly continue to propel MedOne forward,” said Hartig. 

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Dr. Harold was named a 2023 Rising Star by the Telegraph Herald. He earned his Doctorate of Pharmacy degree from the University of Iowa after completing his undergraduate studies in Chemistry at Iowa State University.

Beyond his professional achievements, Dr. Harold is deeply involved in community service. He currently serves on the Iowa Pharmacy Association Practice Transformation and Legislative Affairs advisory committees, he serves on the Sister Water Project Committee working to ensure clean water access for the people of Tanzania and Honduras, and is an avid supporter of animal welfare and fosters collies through the Collie Rescue of Greater Illinois and the Minnesota Wisconsin Collie Rescue. He is a past member of the Genesis Alumni Board at the University of Iowa College of Pharmacy and past member of the Greater Dubuque Development Corporation Future Leaders Committee.

As MedOne continues to expand its reach and impact, Dr. Harold’s leadership as Chief Pharmacy Officer will be a driving force behind the company’s strategic goals. These include advancing its clinical capabilities, strengthening client partnerships, and achieving measurable results across its core pillars of lowest net cost, health outcomes, and member satisfaction.

The 7 Core Values at MedOne | MedOne News | MedOne - Pharmacy Benefit Solutions
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The 7 Core Values at MedOne

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At MedOne, we take our Core Values very seriously. They shape everything we do from the tone in which we answer calls to the structure of our pricing model. 

Each year, we revisit the values to evaluate how we’re doing as a company as we grow and evolve. They are the foundation of MedOne’s company culture after all. So we evaluate: Are they an accurate representation of the culture we want to build here at MedOne? Are these the values our employees exemplify day in and day out? (We hope so!) Is there anything missing? Have we changed or developed in a way that would justify an edit to the MedOne Core Values? 

This year, we did just that. Our seventh Core Value underwent some workshopping. 2024 brought forth quite a bit of change in terms of product offerings and key capabilities. Therefore, we saw the need to refresh the final Core Value to reflect our innovative mindset. 

Introducing the 2025 MedOne Core Values: 

Prioritize your well-being

This core value is the first core value for a reason. Family and personal well-being is more important than any job or career, and we truly mean that. If your physical body comes to work but your mind is elsewhere, we have an issue. So take care of your mind, body, and soul in whatever way makes sense for you. 

What does this look like?

Take time for family events. Take appropriate breaks throughout your day. Use your PTO (Please! It’s there for a reason!). Ask for help if you start to get overwhelmed. Arrange for coverage and communicate when you need time away. Take care of you. 

Act as a MedOne team

We can't do it alone. Given the growth of our team over the last 3-5 years, we know this one to be especially true. We need to RAVE (Respect, Appreciate and Value Everyone), focusing on the fact that teamwork can look different from person to person or department to department. The unifying factor: We need each other to succeed. 

What does this look like?

Treat everyone with respect. Practice clear, concise, timely communication. Give credit for support, help, or ideas when it’s warranted. Consider the impact of plans and actions across departments (not just your own). Create common strategies that support each other. Get to know your team and let your team get to know you - be open.

Care for members with compassion

Members are at the heart of what we do; they’re why we come to work each day. Members are not numbers. They are people with needs and we are in the fortunate position to help them navigate the wild world of healthcare. We strive to simplify the complicated and do so with empathy and compassion.

What does this look like?

Listen to members with empathy. Go the extra mile. Use language that confirms you understand their situation. Help them like you would a loved one. Work with purpose to resolve their issues. Practice 360 degree communication - If we can't resolve the member's issues immediately, we'll reach out to the provider, pharmacy and circle back with the member on the resolution progress within 24 hours. Don't make it hard for our members.

Strive to exceed client expectations

Prove we are reliable and effective from the get-go. Each interaction should leave our clients educated, satisfied, and happy. We need to earn our role as a key, strategic, and trusted partner to our clients.

What does this look like?

Foster positive and mutually beneficial relationships. It is important to manage expectations in an effort to under-promise and over-deliver. Solve current and future problems - we should work to anticipate, predict and address our client's questions before they pose them. Overperform against minimum contractual guarantees. Educate clients to make sound business decisions. Provide detailed reporting and make proactive recommendations to solve customer problems. Communicate clearly, concisely and accurately. Listen to customer feedback. Be enthusiastic. Be unexpected.

Do the right things for the right reasons

This is at the core of our founding story. Our founder saw things in our industry that he didn’t believe were right. Honesty and integrity drive our decisions. We differentiate ourselves by always explaining the "why" behind our actions in an industry where it is difficult to get a straight answer. While we need to make money, profit is not our only motivator. Overall, the focus of this Core Value is to just be a good human. This is the #1 thing we hire for. We can teach the ins and outs of PBM, what a PA is, and how to run a report. But we can’t teach you how to be a good person; that’s on you. And we expect that from each and every one of our employees (as well as our vendors and partners). 

What does this look like?

Take the right path, not the easy one in our daily interactions with the team, clients, and members. Be transparent and upfront. The toughest conversations are where we see growth and trust start to build. Overall, just be a good human. 

Bring your best

We are professionals and we need to bring our A-game to work. Continued focus on process and procedure will help us reach our goals with relatively few pain points. Mistakes will happen. When they do, we will seek out the process failure rather than someone to blame with the goal of preventing the problem from recurring. We will hold each other accountable to the process or procedure. Showing up better today than yesterday.

What does this look like?

Show up on time. Come prepared to meetings. Plan ahead. Don't give bad / inaccurate information. If you need to confirm and follow-up, confirm the information and follow-through on the follow-up. Be true to your word. Be clear about who is responsible for what. Be personally accountable. Ask what (happened/where breakdown was) not who.

Create & embrace positive change

This seventh and final Core Value underwent some workshopping this year. Previously, we rounded out the list with “Challenge the status quo” which is a great value to live by and still something we expect of our employees. The edit taking effect in 2025 extrapolates on this idea and prioritizes what happens after the “challenge.” What are we doing about the identified need for change? It must be acted upon; we need to both create AND embrace change in a positive manner in order to move forward. 

After all, there are only two options: make progress or make excuses. During onboarding, we ask each employee to “poke holes” in our processes. Ask why we do things the way that we do. Don’t be shy! This innovative mindset is where we see true growth and advancement. Our employees can take pride in the fact that by creating and embracing positive change, they are actively contributing to improving the MedOne experience.

What does this look like?

Ask WHY. And then ask it again. And maybe a third time. Drill down to get to the bottom of faulty functions or processes. Don't conform, offer your perspective. Work to eliminate redundancies or unnecessary steps (ie: Work smarter, not harder). Be innovative and stretch yourself. Don't rest on your laurels. Do better than you did yesterday. Measure and celebrate improvements.

Most companies have a set of core values. They’re often displayed on website or hung in lobbies, but how often are they practiced? Or even discussed? We challenge you to talk about them. Evaluate them. Expect them. From every employee at your organization. 

A Makeover at MedOne | MedOne News | MedOne - Pharmacy Benefit Solutions
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A Makeover at MedOne

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Exciting things are happening over here...

MedOne is persistently evolving and creating new ways in which we can better serve our clients and members. We would like to bring your attention to the pharmacy ID card members on the benefit receive. 

The New MedOne ID Card

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What is changing?

MedOne created a new design for the MedOne member ID cards. The MedOne ID cards - pertaining to the Rx benefit only - look different than they have in the past. 

The processing information, that the pharmacy uses, has not changed. We simply redesigned the front to make the key information stand out, and the back to feature a scannable QR code that directs members to the myMedOne Member Portal. Overall, this redesign provides more information with a sleeker, more modern design.

Why is this change occurring?

We identified the need to better brand our ID cards and make it clearer to members that the card was specific to their pharmacy benefit. The new design also makes key information easier to find for those entering the information at the pharmacy.

What can members expect?

Current ID cards are valid and members can continue to use them. Should a new ID card be requested in the future, the member will receive a card with the new design. Starting September 1, 2024, all MedOne-issued ID cards will feature the new design and will come in the mail in a two-card punch-out-style mailing.  

Nothing is changing for members who receive a combined medical & Rx ID card; these changes pertain only to MedOne-issued ID cards pertaining to the Rx benefit only. 

Will this affect active ID cards?

No, any currently active and valid ID card members have will stay active and valid. Should they request a new one, members will receive the new design shown above.

Is there any action needed by the plan sponsor?

There is no action required at this time.

If you have any questions or concerns about this new ID card design, please reach out to your MedOne account team. 

Enhancing Member Experience: Ongoing myMedOne Updates | MedOne News | MedOne - Pharmacy Benefit Solutions
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Enhancing Member Experience: Ongoing myMedOne Updates

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Enhancing Member Experience: Ongoing myMedOne Updates

At MedOne, we strive to continuously evolve to ensure our members experience seamless access to their pharmacy benefit information. With this commitment in mind, we're  introducing a range of new features to the myMedOne Member Portal that our development team has been diligently working on. These features include an "Act As a Dependent" feature, additional information on the “My Rx Lookup” tool, and “My Rx Lookup Filtering, Sorting, & More Pricing Results.”

Act As a Dependent

The primary cardholder on a benefit can use a new drop-down option to access information on other dependents under age 18 that are covered on the benefit. This view allows them to “act as their dependent” on myMedOne. This functionality enables the member to utilize myMedOne as if they were logged in as their dependent. This includes:

  • Viewing the dependent's progress towards deductibles and out-of-pocket expenses in the "My Progress" card.
  • Accessing the dependent's fill history through "My Recent Rx Fills" and "My Rx Fill History."
  • Reviewing the dependent's prior authorizations via "My Prior Authorizations."
  • Pricing medications and accessing coverage information as the dependent via "My Rx Lookup."

How It Works

If the user has permission to access dependent information, they will notice a drop-down menu titled "Member" in the application header. From this drop-down, users can view who they are currently acting as and can switch to another member by selecting them from the menu. Upon selecting a different member, the cards and pages within the application will update to display the dependent's information.

If a user does not have access to a dependent, they will not show in the dropdown. Furthermore, if a user doesn't have any dependents, no dropdown will be displayed.

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Limitations and Restrictions

The feature comes with certain limitations, which include:

  • This feature is exclusively available for the primary cardholder (01). 
  • Access to a spouse's information is not permitted due to HIPAA restrictions, even if they are listed as a dependent. However, this capability is planned for future development and implementation into the myMedOne Member Portal. 
  • Only information for dependents under 18 years of age is accessible. Once a dependent reaches legal adulthood, their information becomes inaccessible.

My Rx Lookup | Pricing Disclaimer

In the My Rx Lookup feature, members are now required to agree to the pricing result disclaimer. There are many factors that affect drug prices. These fluctuate often and many are out of the control of MedOne. Therefore, it is important to note that while we strive to provide accurate pricing information, we cannot guarantee with 100% certainty the exact medication and price that a given pharmacy will fill. This update aims to inform members of any potential discrepancies. Additionally, we have enhanced the visibility of the pricing disclaimer on the pricing results page to ensure members are fully aware of this information.

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My Rx Lookup | Filtering, Sorting, & More Pricing Results

MedOne has introduced the option to filter and sort pricing results within the My Rx Lookup feature. Members now have the capability to narrow down pricing results to specific pharmacies. Additionally, members can sort the results by:

  • Distance (Near to far)
  • Member Pay (Low to High)
  • Member Pay (High to Low)
  • Plan Pay (Low to High)
  • Plan Pay (High to Low)
  • Pharmacy Name (A - Z)
  • Pharmacy Name (Z - A)

This helps member find the information that’s most important to them first and all around aids in the navigation through the My Rx Lookup tool. 

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Additionally, we've expanded the number of pricing results available for a single zip code, enabling members to view more options in their local area.

If you are an existing member of a MedOne pharmacy benefit plan, discover these new features on the myMedOne member portal at my.medone-rx.com. Register using the member ID number found on your insurance card to unlock these enhancements.

Unlocking Better Pharmacy Benefits | MedOne News | MedOne - Pharmacy Benefit Solutions
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Unlocking Better Pharmacy Benefits

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Empowering MedOne Members with New Features | MedOne News | MedOne - Pharmacy Benefit Solutions
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Empowering MedOne Members with New Features

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MedOne is proud to unveil the latest enhancements to the myMedOne Member Portal: "My Prior Authorizations" (PA) and "My Rx History." 

The addition of these two features are pivotal in our mission to equip all MedOne members with the tools they need to access and understand their pharmacy benefit.

“We are excited to provide members with an unmatched level of insight and transparency into the prior authorization process.

Dr. Nate Harold, VP of Clinical Services

Prior authorizations account for roughly 60% of inbound call volume to our Member Advocate team. Equipping members with the ability to check the status of their PAs eliminates the need to call in, giving them access to the information they need faster than has been historically possible. 

Dr. Nate goes on to say, “We understand that prior authorizations are a major cause of frustration for providers and patients alike. By giving members a greater level of insight and expectation management, we are bringing new levels of alignment to ensure members can obtain the most appropriate treatment at the best price.”

My Prior Authorization

Accessible via the myMedOne landing page or the slide-out navigation, the "My Prior Authorizations" screen aims to inform members about the status of their prior authorizations. This screen showcases both current and past PAs, presenting a range of statuses. Possible status messages include: 

  • Approved
  • Partially Approved
  • In Progress
  • Expiring
  • Expired
  • Denied
  • Aborted

Members are empowered with actionable insights corresponding to these statuses, allowing them to actively participate in their prescription journey.

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My Rx History | Sort, Filter, & Pagination

MedOne has also introduced pagination to the My Rx History page. Initially displaying 10 fills per page, sorted from newest to oldest, members can seamlessly navigate through pages to access their prescription claims history. 

Members now enjoy the flexibility to sort and filter their claims, particularly beneficial for those with extensive fill histories.

Sort options include:

  • Fill date
  • Medication name
  • Member pay
  • Plan pay

Filter options encompass Year, Medication, and Pharmacy.

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MedOne is committed to empowering our members. These myMedOne enhancements, as well as the many which are to come, help ensure that MedOne members have easy access to the information they need most. Additional updates and feature launches are slated to continue throughout 2024 and beyond. If you have any questions concerning your pharmacy benefit or myMedOne, please contact our Member Advocate team at 888-884-6331.

If you're a member of a MedOne pharmacy benefit plan, discover these new features on the myMedOne member portal at my.medone-rx.com. Register using the member ID number found on your insurance card to unlock these enhancements.

A Moment from MedOne: March 2024 | MedOne News | MedOne - Pharmacy Benefit Solutions
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A Moment from MedOne: March 2024

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On behalf of all of us at MedOne, we appreciate the opportunity to serve all our customers. We are especially appreciative in combination with our upcoming 25th anniversary in early April. Going back to our roots since being founded in 1999, we are passionate about being private and family-owned, and our 100% transparent, pass-through model that has existed since Day 1.

What's New in Pharmacy?

This newsletter provides a quick touchpoint on some news and happenings across the industry. It also allows us to say a friendly "hello" and connect to say thank you for being part of the MedOne family.

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Our thoughts on the Ozempic lawsuit.

Have you heard? Over 10,000 patients have filed adverse event reports against specific GLP-1s (article link below), claiming inadequate warnings of severe side effects. The most common? Gastroparesis – a chronic condition where the nerves and muscles in the stomach wall severely weaken. GLP-1s were not originally designed to be an anti-obesity drug. They are a Type 2 diabetes therapy.

In 2023 at MedOne, Ozempic prior authorization denials were more than double the number of denials for any other drug. The major reason for the denials was due to off-label use (anti-obesity).

As new weight loss drugs (Wegovy, Zepbound, etc) come to market, MedOne has developed strategies to help employers know when and where it makes sense to cover these drugs.

View full article on LinkedIn.

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Insulin price cap takes effect, lowering costs for many Americans.

View full article from USA Today.

Push for Stelara Biosimilar: The Next Humira

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Stelara has held the position of J&J's leading revenue-generating drug since 2019, but its crucial patents began to expire last year. In June, Alvotech and its Israeli partner, Teva Pharmaceutical, entered into a settlement and licensing agreement with J&J for the introduction of the biosimilar, AVT04, no later than February 21, 2025, contingent upon receiving U.S. FDA approval. The regulatory decision is anticipated by April 16. Although a significant Stelara patent expired in the United States last year, J&J secured agreements with competitors to postpone the launch of their biosimilars until 2025. Amgen is set to be the first to introduce its comparable product, Wezlana, in the coming year.

View full article from Fierce Pharma.

Coverage Change for Vyvanse (Lisdexamfetamine)

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ADHD Medication Shortage

We are heading into the second year of experiencing a nationwide shortage of ADHD medications such as Vyvanse, Adderall, and their generic alternatives. Regardless of the cause, MedOne is committed to ensure members have access to an appropriate prescription at an affordable cost.

Formulary Change

Some brands like Vyvanse are excluded from the Performance Formulary due to the availability of generic alternatives. The MedOne Formulary Subcommittee meets weekly to evaluate market changes and adjust formularies as necessary.

Recently, the Subcommittee discussed the shortage of ADHD medications. They evaluated the cost impact and the impact on clinical outcomes and member/client satisfaction and determined it was best to allow brand Vyvanse on formulary in a non-preferred tier until the generic becomes readily available.

Contact your MedOne Account Management team for additional details.

Read more information about the formulary change.

Regulation Watch

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Federal Trade Commission Chair Targets PBMs

Amidst an FTC investigation of PBM middlemen, Commission Chair Lina Khan relays the “Big 3” haven't filly cooperated. “So far, the PBMs have not fully complied with our orders to turn over documents and data,” she said. “FTC orders are not suggestions and we will not hesitate to use the full extent of our legal authorities to mandate compliance.”

View full article from Ohio Capital Journal.

Government Entities Launch Inquiry

The FTC, the Department of Justice's (DOJ) Antitrust Division, and the U.S. Department of Health and Human Services launched and RFI on “deals conducted by health systems, private, payers, private equity funds, and other alternative asset managers that involve heath care provider, facilities, or ancillart products or services.”

View full article from The FTC.

Consolidated Appropriations Act

Under the Consolidated Appropriations Act (CAA), self-funded group health plans are required to report data annually regarding prescription drugs and health care spending to the Departments of Health and Human Services, Labor, and Treasury (Tri-Agencies). The next due date for submission is June 1, 2024, and will encompass 2023 data. This data is submitted via a Centers for Medicare & Medicaid Services (CMS) web portal.

To support our clients’ self-funding group health plans, MedOne will submit the P2 and D3 – D8 files along with a narrative response for plans directly to CMS. (Please note, medical administrators may also be required to send some of these files, as per the CAA.) Our submission will include plans which had active coverage with MedOne during the reference year (2023).

If you have questions about the MedOne submission process, please reach out to Laurie Stowe, VP of Account Management, at lstowe@medone-rx.com.

Cyber Attack on Change Healthcare Carries Worldwide Impact

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What Happened:

As you may know, all pharmacies hire a switch vendor to route claims from their pharmacy management system to PBMs like MedOne. One significant switch vendor is Change Healthcare who is experiencing an outage (starting around 11:05 AM EST on 2/21/2024) preventing claims from reaching PBMs like MedOne. Various pharmacies and PBMs have confirmed this is an industry-wide issue and not isolated to MedOne. We're now learning, it's not isolated to pharmacy claims either. 

Service to MedOne members was impacted for a short time and while the Change Healthcare outage persists, MedOne found an alternative solution. 

Our Solution

MedOne was able to establish connectivity to receive claims from an alternative switch vendor named RelayHealth.

All pharmacies using RelayHealth will now be able to successfully submit claims to MedOne. While we believe many pharmacies have pivoted to RelayHealth, there still may be pharmacies unable to process claims. For those instances, we have some alternatives and workarounds in place. Please contact your MedOne Account Management team for additional details.

Read more about the outage from WIRED.

Save the Date!

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MedOne is celebrating 25 years in business here in April!

If you're local to the Dubuque area, please plan on joining us for an open house and ribbon cutting on Friday, April 12 from 7:30-10:00AM.

RSVP here.

Prescription Claims Processing Notice | MedOne News | MedOne - Pharmacy Benefit Solutions
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Prescription Claims Processing Notice

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As of 2/27/2024 3:14 PM CST, MedOne has successfully established connectivity with an alternative routing vendor and claims are processing.

MedOne is now processing claims through RelayHealth, and all pharmacies using RelayHealth will now be able to successfully submit claims to MedOne. For members who may have paid out of pocket over the past few days, we encourage them to work with their pharmacies to reverse and reprocess their prescriptions through insurance to avoid having to submit a Direct Member Reimbursement form to be reimbursed.

While we believe many pharmacies have pivoted to RelayHealth during the outage, there may still be pharmacies unable to process claims. For those instances, we reinforce our previous communication and resolution strategy noted in prior communications.

For any members needing assistance, please encourage them to contact our Member Advocate team at 866-335-9057.

What Happened: 

On Wednesday, 2/21/2024, Change Healthcare, part of UnitedHealth Group, suffered a cyber security attack from a suspected nation-state per its SEC filing. Among other services, Change Healthcare supports the routing of prescriptions from pharmacies to PBMs. In response to said attack, Change Healthcare disconnected its prescription routing service to limit impact. As of 2/28/2024 at 8:07AM EST, the outage persists. Change Healthcare expects the disruption to “last at least through the day.” 

Updates directly from Change Healthcare may be found here:

https://status.changehealthcare.com/incidents/hqpjz25fn3n7

For clarification, MedOne systems and data were NOT the target of the cyber security attack. Our systems were not affected or impacted. At this time, there is no indication that MedOne systems or data have been compromised. Claims that can be successfully routed from a pharmacy to MedOne will correctly process.

MedOne is committed to ensuring access to care for our members and apologize for any inconvenience our members may experience. For escalated member issues, MedOne has an Emergency Response Team to assist members in securing their emergency medications during this outage. 

We are actively monitoring the outage to keep abreast of adjudication status and downstream impact. Please contact your account manager or the MedOne Member Advocate Team at 866-335-9057 with any additional questions at this time.

Formulary Notice: Coverage Change for Vyvanse | MedOne News | MedOne - Pharmacy Benefit Solutions
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Formulary Notice: Coverage Change for Vyvanse

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ADHD Medication Shortage

We are heading into the second year of experiencing a nationwide shortage of ADHD medications such as Vyvanse, Adderall, and their generic alternatives. Regardless of the cause, MedOne is committed to ensure members have access to an appropriate prescription at an affordable cost.

Formulary Change

Some brands like Vyvanse are excluded from the Performance Formulary due to the availability of generic alternatives. The MedOne Formulary Subcommittee meets weekly to evaluate market changes and adjust formularies as necessary. Recently, the Subcommittee discussed the shortage of ADHD medications and decided to adjust the Performance Formulary Exclusions. They evaluated the cost impact and the impact on clinical outcomes and member/client satisfaction and determined it was best to allow brand Vyvanse on formulary in a non-preferred tier until the generic becomes readily available.

What This Means For You

When you go to the pharmacy to fill your preferred generic ADHD medication, your pharmacy may not have it. There are two options: 

Option 1
You can call MedOne and ask that they help source the prescribed generic at another nearby pharmacy or to see if other generics are available at your pharmacy.

Option 2
The pharmacy may dispense Vyvanse. However, please note that any brand medication that is dispensed is subject to any applicable brand copay. 

If you have NOT previously been prescribed Vyvanse or a similar brand, you may be subject to Step Therapy and Prior Authorization requirements. You may be required to step through two (2) preferred generic long acting stimulants before the plan would  allow a brand long-acting stimulant (Vyvanse or otherwise).

Please Note: DAW penalties will still apply. If you request a brand when a generic alternative is available, you will be required to pay both your brand copay PLUS the difference between the prescribed generic and the requested brand.

Please contact your MedOne Account Management Team for additional details.

Meet the New myMedOne Member Portal | MedOne News | MedOne - Pharmacy Benefit Solutions
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Meet the New myMedOne Member Portal

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DUBUQUE, January 12, 2024 — MedOne Pharmacy Benefit Solutions is proud to announce a new digital member experience called myMedOne that will change the way MedOne members look at their pharmacy benefits. 

"Our goal with myMedOne is to help our members more easily understand and access their pharmacy benefit."

Wes Hartig, CEO of MedOne

myMedOne, accessible at my.medone-rx.com, is available to individuals enrolled in a MedOne pharmacy benefit plan through their employer. All features of the myMedOne member application are designed to generate an efficient and streamlined member experience. Key features include an active tracker that records a member’s progress toward individual and family deductibles and out-of-pocket maximums; a comprehensive history of all prescription fills to date; easy access to pertinent plan information such as ID card processing information, pharmacy networks, and copay structures; ability to enroll in mail order; options to schedule a one-on-one consultation with an on-staff clinical pharmacist and more. 

Under the leadership of VP of IT Kyle Fisher, MedOne looked to Application Architect Andrew Ward, along with senior developer Nathan Luebbert and developers Irmak Erdem, Hector Morales, and Wilbert White to exclusively in-source the build of the portal. 

"Building myMedOne in-house allows us to leverage cutting-edge technology in order to empower and equip our members with a beautiful, easy-to-use portal that is curated to our members' specific benefits and needs," says Fisher. 

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Much of the feature focus surrounded the My Rx Lookup feature. This interactive tool allows members to search for a medication and see how it is covered on the specific member’s benefit as well as compare prices for the medication in a geographic area allowing the member to identify the most cost-effective pharmacies in their area. 

"MedOne is aligned with our clients’ success and our clients are aligned with their members’ success. When the member makes the right decision, we all win. This is how pharmacy benefits should work. We are focused on helping MedOne members get to the right medication at the best price as efficiently as possible. The launch of myMedOne is a significant step in furthering this goal," says Hartig. 

If you are a member of a MedOne pharmacy benefit plan, explore the new myMedOne member portal by visiting my.medone-rx.com and register using the member ID number found on your insurance card.

MedOne Partners with Mark Cuban Cost Plus Drug Company | MedOne News | MedOne - Pharmacy Benefit Solutions
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MedOne Partners with Mark Cuban Cost Plus Drug Company

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DUBUQUE, IOWA, August 18, 2023 — MedOne Pharmacy Benefit Solutions, a performance-based PBM serving employers nationwide, has integrated with Mark Cuban Cost Plus Drug Company, PBC (Cost Plus Drugs) to provide its members with easy access to more cost-effective medications.  

Effective August 18, MedOne members will have access to pricing and rates per Cost Plus Drugs' pharmacy and, when utilized, all patient spend will track to the patient's deductible and out-of-pocket maximum.  

Committed to providing a better benefit experience, MedOne's pass-through approach to PBM aligns with Cost Plus Drugs’ completely transparent philosophy. Just as MedOne passes all upside through to its clients, Cost Plus Drugs cuts out the middleman and negotiates directly with manufacturers to obtain the best possible prices, passing along those savings to the end patient. This results in easy access to safe, affordable medications for anyone who needs them in an industry historically layered with extra costs and price inflation.  

“As a practicing physician I saw first-hand the danger of patients not taking their medications because they couldn't afford them,” said Alex Oshmyansky, CEO of Mark Cuban Cost Plus Drug Company. “I founded the Mark Cuban Cost Plus Drug Company to help solve this problem and provide a way for patients to receive their medication at an affordable price." 

Notably, MedOne members can now access YUSIMRY™, a biosimilar of HUMIRA®, through Cost Plus Drugs for more than 90% less than the list price of HUMIRA®. MedOne covers YUSIMRY™ as a preferred medication and it is available to MedOne clients and members for $569.25 plus dispensing and shipping fees. 

"We support a future where pharmacies and manufacturers are able to set their own prices, which are extended to plans and patients without adjustment. We can’t accomplish this alone and we are excited to collaborate with Cost Plus Drugs.

Wes Hartig, CEO of MedOne.   

"We view it as our job to embrace innovators like Cost Plus Drugs and empower plans and patients to make the best choices,” said Wes Hartig, CEO of MedOne.    

Transparent and pass-through since 1999, MedOne's performance-based approach to PBM includes guaranteed results for its plan sponsor clients. MedOne goes at-risk to ensure all financial guarantees are met. Layering in the relationship with Cost Plus Drugs provides additional savings for both the plan sponsor and member. 

 "We already offer transparent, low prices to cash-pay consumers and are excited to now be working with PBMs like MedOne to further reduce the cost to patients, and to keep the patient record complete from both a clinical and financial perspective," said Oshmyansky.

To learn more about the MedOne model, please contact sales@medone-rx.com.

New Integration Streamlines MedOne Prior Authorization Processes | MedOne News | MedOne - Pharmacy Benefit Solutions
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Press Release |

New Integration Streamlines MedOne Prior Authorization Processes

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DUBUQUE, March 21, 2023 — MedOne Pharmacy Benefit Solutions, a Dubuque, Iowa-based PBM (pharmacy benefit manager) announces a new collaboration with CoverMyMeds that will allow members enrolled in a MedOne benefit plan to experience a streamlined prior authorization process via direct integration with CoverMyMeds' network of prescribers, EHR (electronic health records) systems, pharmacies, and pharmacy system vendors. This benefits both members and prescribers - helping reduce the amount of time between when a medication is prescribed and when it reaches the hands of the member. 

MedOne offers custom-built pharmacy benefit plans that employ a series of cost containment strategies in addition to operating on a pass-through model. These strategies, while cost-conscious in nature, ensure the appropriateness of medications prescribed to members enrolled in a MedOne plan. One of the most common strategies involved is the use of a prior authorization. This is a review conducted by an on-staff clinical pharmacist and ensures the safest and most cost-effective option within a therapeutic class is used as the first line of treatment. Prior authorizations are typically conducted on high-cost medications.

“Prior authorization continues to be an effective tool in helping ensure the treatments funded by our clients are safe, effective, and prescribed appropriately. The clinical information received and reviewed is critical in ensuring our members are treated with high performing treatments and setup to achieve positive health outcomes,” said Dr. Nate Harold, VP of Clinical Services at MedOne.

The process for conducting prior authorizations has evolved but often requires paperwork to be faxed to/from the prescriber's office and MedOne. The integration with CoverMyMeds leverages the use of ePA (electronic prior authorization), which helps eliminate the need for additional or dual paperwork to be submitted. This, in turn, minimizes the delay in claims processing, helping members to access their medications more quickly without sacrificing the process for determining a prescription’s therapeutic appropriateness.

“It is clear that prior authorization and the process of obtaining and reviewing clinical information has become an increasing burden on our healthcare system and specifically our providers.  As technology has advanced, we are in an ideal position to address these challenges to streamline the process, improve the time patients wait for a decision, improve information accuracy, and elevate the labor-intensive process of prescribers submitting clinical information. CoverMyMeds’ ePA solution provides a fast and easy way to complete prior authorization requests for our clients, pharmacies, prescribers, and most importantly, our members,” said Dr. Harold.