Why Well-Managed Plans Don’t Just Happen

Jul 25, 2017
Formulary management, utilization management, channel management and clinical specialization define well-managed pharmacy benefit plans.

Kyle Shayna Article

If all U.S. pharmacy plans had more tightly managed their benefit last year, the United States could have saved nearly $6 billion on its prescription drugs bill. Tightly managed plans don’t just happen. Instead, they are based on key strategies and solutions that complement each other to drive down costs and deliver better clinical value.

The data are clearly in favor of more tight management of benefit plans. According to our 2016 Drug Trend Report, plans employing four or more cost-saving, clinical solutions had drug trend of just 2.6% last year, far less than average plan (5.4%) or a lightly managed plan (9.6%). Clients that tightly manage their benefit realize lower spend per member per month and lower year-over-year trend while providing consistent, dedicated care for their members.

Here are four strategies to make this happen:

1. Formulary Management

An effective formulary opens access to all clinically superior medications while eliminating options that offer no added clinical benefit and have higher costs.

A careful approach is critical to the complex process of building a formulary, but the savings can be significant. Express Scripts 2017 National Preferred Formulary (NPF) opens up access to all clinically superior medication and excludes a handful of "me-too" products that have no clinical benefit beyond what's provided by more affordable alternatives. The leverage to negotiate more effectively with manufacturers means lower drug prices for payers and patients.

2. Utilization Management

Prior authorization, step therapy and drug quantity management programs are important examples of ways to guide patients to safer, more cost-effective drug choices, using clinically based criteria designed to ensure that the patient gets the correct medication in the right amount.

As new drugs come to market and indications for existing medications evolve, it’s critical that plans regularly review and update their utilization management programs. Express Scripts’ SafeGuardRxSM programs incorporate utilization management rules to protect patient safety and keep plan costs in check.

3. Channel Management

Leveraging a specific network of pharmacies, home delivery or 90-day prescriptions can drive down costs for both plans and patients while still offering choice, minimal member disruption and better patient care. Research shows that patients who fill 90-day maintenance medications at either home delivery or retail are 85% adherent to their medicine compared to 66% at 30-day retail.

4. Focused Care and Cost Management

Complex conditions such as diabetes, cardiovascular disease, cancer and multiple sclerosis require specialized care. Specialist pharmacists and clinicians at Express Scripts and Accredo Therapeutic Resource Centers® help patients better manage their specific conditions to achieve better health outcomes. For example, patients with hepatitis C and rheumatoid arthritis achieve adherence rates that are 9% and 16% higher, respectively, than patients who fill their prescriptions at retail pharmacies. Accredo patients with bleeding disorders have 33% fewer central venous line infections, resulting in lower overall medical costs and an improved quality of life.

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Lab Staff
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