The Process of Getting Members Safe and Convenient Access to Medications

Like everything in the healthcare industry, the pharmacy space is continually changing, from regulations to pharmacy locations coming and going. It is important for a pharmacy benefit manager (PBM) to regularly update its pharmacy network to meet these changes and ensure the best access for members. At Elixir, that responsibility falls on Amy Karfeld, vice president of pharmacy network management, a six-year veteran of the company. We sat down with Amy and asked her to talk more about her role at Elixir and helping ensure members have access to their needed medications.

One function of Amy’s team is managing the credentialing of pharmacies to make sure they meet Elixir’s requirements to join our expansive network, including licensing and regulatory criteria. “We’re always credentialing pharmacies as new ones open and updating our network as stores close, reviewing our criteria to meet the evolving market,” Amy said. “Recently, we’ve seen a lot of the largest pharmacy chains announcing store closures. It’s ongoing, store openings and closures.”

Amy’s team also needs to keep on top of the ever-changing regulations that govern PBMs, including changes to allowed pricing, working with our Legal department to understand the changes and ensure our network pharmacies and operations meet the requirements.

Her team regularly re-credentials pharmacies and performs periodic audits to make sure they continue to meet network criteria and there are not any sanctions, suspensions or terminations of licensure. In 2021, over 200 pharmacies were suspended from our network for not meeting requirements. This diligence protects our clients and members from potential unscrupulous behavior and is important given the number of pharmacies opening and closing on a regular basis.

Amy also notes a trend of increased specialty drug utilization. While only approximately 1% to 3% of prescriptions are for complex specialty medications used to treat conditions such as multiple sclerosis, Crohn’s disease and certain cancers, they account for nearly 50% of drug spend.[1]

Because of the complex nature of these drugs, many manufacturers limit distribution of these products, known as LDDs, selecting specialty pharmacies that have expertise in the condition and a thorough understanding of the handling and administration needs of the medication.

Working with our Specialty Solutions department, Amy’s team contracts with an exclusive network of specialty pharmacies, including our own Elixir Specialty, that are selected as being the best in managing their respective therapeutic categories of specialty drugs. This provides our members with maximum access to specialty drugs and LDDs, ensuring continuity of care and optimal savings.

While this tactic has been around for a while, Amy still sees narrow networks as a trend where one or two pharmacy chains are excluded from a network in order to increase savings. This is because pharmacies are generally willing to provide deeper discounts if they are part of a narrow network of providers.

“It’s a bit of misnomer,” Amy explained. “Narrow makes you think that it’s small, but by only excluding one or two pharmacy chains, members still have access to tens of thousands of pharmacies, some less than a mile from their home.”

At Elixir, we call it a Focused Network. Amy’s team takes a consultative approach, working with clients to determine their options. “There’s a lot of flexibility. We have a process for running different scenarios and sharing the results with our clients,” Amy said. “We can do a lot with geo-access to show the proximity of pharmacies. Narrowing a network is a great way to save money.”

The Right Mix for Elixir

While all of these trends might seem like a lot to keep up with, that’s what Amy enjoys. “Healthcare is very complex, ever-changing and challenging. That’s why I find the industry interesting,” stated Amy, who received a degree in Industrial Engineering from Northwestern University. “Engineering is about process improvement and using data to inform decisions and there’s a space for that in the healthcare industry.”

Amy is using her process improvement and data analytics skillset to increase the efficiency of her team, which includes several areas. The Pharmacy Network Management department works with pharmacies from when they first join the network, having gone through the credentialing process, throughout the relationship with Elixir. This includes determining the pricing strategy and contract terms, and ensuring contractual obligations are met.

With recent department organizational changes to streamline processes, Amy says, “There’s more collaboration and insight.” All of this ensures members have safe and secure access to medications and both plans and members are getting the right price.

Besides enjoying the challenge of working in healthcare, Amy appreciates the personal aspect. “I also like that it’s related to member care, helping people get the right medication at the right time and location,” Amy explained. “I can see the results of our work every day on a personal level when I get prescriptions for my family.” Amy has been married for 16 years and has two daughters, ages 10 and 12.

Also holding an MBA from the University of Chicago, Amy started her career with another PBM 20 years ago in Trade Relations. She then went on and worked at other healthcare companies, including Blue Cross Blue Shield plans and IBM Watson Health, before returning to pharmacy benefit management and joining Elixir nearly six years ago.

When speaking of her team and work at Elixir, Amy said, “The team continues to evolve. We have a stronger understanding of pharmacy data and can do more analysis to help craft the right pharmacy network for our clients. They’re an amazing team. I really enjoy working at Elixir. It’s challenging and interesting work and the people are great: hard workers, strong problem solvers and proactive. It makes every day more enjoyable.”

Amy is just one example of the professionals at Elixir who do more than just their job and really work to help members achieve whole health for life. Throughout the year, we will profile other Elixir leaders and how they’re making a difference.

Karfeld_blog picture cropped

Name: Amy Karfeld
Title: Vice President of Pharmacy Network Management
Tenure with Elixir: Six years
Education: Industrial Engineering degree from Northwestern University and MBA from the University of Chicago Booth School of Business
Family: Married for 16 years with two daughters, ages 10 and 12
Hobbies: Hiking, skiing, running, volunteer coaching for Girls on the Run

Pictured left: Amy and her family rooting for her alma mater at a football game.

[1] Seymore, Brandeis (2020). Challenges of Channel Management for Specialty: Medical Benefit or Pharmacy Benefit. Pharmacy Times. July 10, 2020.