Closely Managed Plans Mitigate Spend Increases

Mar 10, 2015
Plans sponsors who actively manage their pharmacy benefit achieve lower costs, while improving care for members.
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In 2014, the pharmacy landscape underwent a seismic change, and the budgetary impact to healthcare payers was significant. U.S. prescription drug spend increased 13.1% in 2014 – the largest annual increase since 2003 – and this was largely driven by an unprecedented 30.9% increase in spending on specialty medications.

Express Scripts’ clinical solutions – which leverage decades of experience and innovation – help plan sponsors optimize drug utilization and costs. Programs such as formulary management, copay differentials, step therapy programs, home delivery and our Accredo specialty pharmacy, help payers align patient care and benefit affordability, with minimal member disruption.

Multiple Strategies = Greater Savings

More than 15% of Express Scripts’ clients spent less on prescription drugs per capita in 2014 than they did in 2013.

A sub analysis of the 2014 Express Scripts Drug Trend Report found that, compared to payers with less managed pharmacy plans, payers that implemented four or more cost-management programs achieved nearly zero drug trend and spent nearly 30% less per member on traditional (non-specialty) medications, those which treat common chronic conditions, such as diabetes.

In addition, clients’ drug spending decreased with each solution they used, and the spending was exponentially less with each added program.

Significant Impact of Our Traditional Trend Management Solutions

The analysis also revealed that utilization management programs are most impactful when paired with use of the Express Scripts Home Delivery Pharmacy. Plans that paired home delivery with copay differentials, formulary management and step therapy saved up to an additional 12% to 19% on drug spending.

Traditional Trend Management Strategies

Taking Action Cuts Specialty Spend Increases

In an expansion of a 2013 study, researchers at the Express Scripts Lab examined the effect of specialty utilization management programs on 851 employers, 20% of which did not implement a network or therapy management program.

The analysis showed the annual increase in specialty drug spending is 32% less for employers with a tightly managed specialty pharmacy benefit compared to employers with an unmanaged benefit, and 18.5% less than employers with a managed benefit. In addition, tightly managed programs saw higher average medication adherence rates in top specialty therapy classes, such as multiple sclerosis and pulmonary conditions. Due to our specialized pharmacy approach, plan sponsors can control their costs while improving the care for members.

Managed Plans by Therapy Class

Research Methodology

In analyzing the impact of utilization management programs on traditional therapy classes (excluding compounded medications), our research team categorized plan sponsors into one of three groups:

  • Unmanaged – Plan sponsors with zero or one programs.
  • Managed – Plan sponsors who implemented two or three of the five programs examined.
  • Tightly managed – Plan sponsors who implemented four or five programs.

The network and utilization management programs examined in the analysis included:

  • 3 or more copay tiers
  • 7 or more Step Therapy/Prior Authorizations rules
  • $20 or more difference between generic and brand preferred copays
  • Express Scripts National Preferred Formulary
  • Exclusive or select use of Express Scripts Home Delivery Pharmacy for maintenance medications

In the specialty utilization management analysis, our research team looked at clients who implemented network management programs (those which limit retail use for specialty medications or require exclusive use of the Accredo specialty pharmacy), and step therapy programs for select conditions, including growth deficiency, respiratory conditions, hepatitis, and inflammatory conditions.

Plans sponsors were categorized as tightly managed if they employed a network management program and two or more step therapy rules. Plan sponsors who employed a network management program and none or 1 step therapy rule were considered managed, and those with an open network and no step therapy rules were considered unmanaged.

Time to Act

There has never been a greater need for plan sponsors to take action to reduce increasing pharmacy costs, maintain an affordable benefit and ensure life-saving medications remain accessible to all patients.

Plans sponsors who currently leverage many of the solutions available are reducing their spending in spite of the rising costs of pharmacy care, and are better poised to address future challenges.

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