Pharmacy benefits plans in the employer marketplace have the potential to play an important role in positively affecting the health and well-being of their plan participants. However, mismanaged or put on the shelf and left to run themselves, these programs can steadily drain an employer’s financial resources – and can even affect the safety of employees.
In part 2 of this series, we look at how helping employees manage their medication regimen can improve the cost effectiveness of the program itself.
Decisions to implement cost-effective pharmacy benefits plans need to recognize the patient’s own behavior. Poor adherence to the drug treatment regimen by patients with chronic diseases can result in expensive hospital care, higher medical and disability plan costs, and increased absenteeism.
But people, being people, are not always good at following drug prescriptions to the letter. A key element in any pharmacy benefit plan involves providing up-front guidance to plan members through a clinical management program, built into the plan terms. Sound clinical programs are critical in managing pharmacy benefit costs by minimizing unnecessary drug use and waste. The overriding objective of clinical programs is to ensure that members receive the right drug for the right condition at the right dose at the right time.
Key elements of a clinical program strategy
- Mandatory generic substitution of patent-expired brand drugs
- Prior authorizations (PAs) for drugs in selected classes
- Quantity limits on certain drugs to meet FDA guidelines for safety and to minimize fraud and abuse
- Step therapy to require a participant who has not previously used a drug in specific drug classes (e.g., cholesterol-lowering drugs) to try a less expensive therapeutic alternative before using a more costly brand drug
- Exclusion of certain drug classes with over-the counter (OTC) versions
- Programs to improve member drug adherence that can lead to improved health and lower medical plan costs and mitigation of disease complications
Next: Part 3: As Pharma consolidates, even smaller employers can negotiate