No one likes surprises, especially when they create negative and unexpected adjustments to rebate guarantees. As we step into 2025, changes in market conditions and regulations are expected to trigger adjustments to existing guarantees. Staying informed and partnering with a trusted, transparent advisor with a client-first approach can help you navigate these shifts with clarity and confidence.
How Your Rebate Guarantees Are Determined
Rebate guarantees are typically based on a thorough review of your unique prescription claims data and known market trends—like new drug launches, patent expirations, and utilization patterns. While these guarantees are meant to provide predictability, most contracts include provisions allowing adjustments when specific changes occur.
This is why it is critical to partner with a company that understands these nuances and offers realistic, transparent guarantees to avoid unexpected disruptions.
Here are some of the most common scenarios that could trigger an adjustment:
- Formulary or Drug Mix Changes: These could include the launch of new biosimilars or a shift to a new formulary type, which could alter rebate yields and require adjustments to guarantee agreements.
- Utilization Management Adjustments: Changes to prior authorization (PA) criteria can significantly influence drug utilization. While manufacturers may allow PA criteria to control utilization, intentionally rigorous PA measures could also negatively impact rebate values.
- The Volume of Claims: Changes in the number of covered lives under a plan can sometimes trigger rebate adjustments
- Regulatory or Legal Changes: Legislation, like the American Rescue Plan (ARP) of 2021, has reshaped rebate calculations and continues to impact commercial plans.
Understanding what can trigger rebate adjustments and having a partner who can provide expertise on when they might occur is key to managing expectations and outcomes.
Why Clarity and Predictability Matter
Navigating rebate guarantee adjustments can be complex, especially when regulatory or market-driven events trigger them. However, plan sponsors don’t have to do it alone. Partnering with a company that believes in providing clients with the right kind of transparency and clarity can make all the difference.
Providing clients with the right kind of transparency at Gateway Health Partners means:
- Clarity: Providing clear and timely communication about changes that may impact rebate yields.
- Insights: Utilizing our clients’ unique data and combining it with our vast industry knowledge and detailed analytics to provide equitable adjustments that are always in your best interest.
- Expertise: Decades of industry experience allow us to create proactive strategies to minimize surprises and financial disruption.
Take Control of Your Rebates in 2025
Navigating rebate adjustments doesn’t have to be overwhelming. Gateway Health Partners specializes in simplifying the process by helping plan sponsors understand, manage and optimize their rebates with clarity, insights and expertise.
Contact us today by emailing [email protected] to learn how we can help ensure your rebate guarantees are built on the right kind of transparency so you don’t leave money on the table while providing optimal outcomes for the patient population you serve.
