Maximize Pharmacy Benefits Before Open Enrollment

As we enter a new calendar year, employers are once again under enormous pressure to prepare clean approaches to managing their benefits spend. This is especially true in the Rx area.

With another open enrollment season in the rearview mirror, your customers can’t afford to take a wait-and-see approach that allows pharmacy benefits managers (PBMs) and drugmakers to dictate the fate of pharmacy budgets. social advantages.

Drug spending in the United States soared to more than $535 billion in 2020 and is expected to increase another 4-6% by the end of 2021. Two culprits are faster price increases and higher growth of use. With rising drug costs and pharmaceutical expenses, reducing the cost of Rx benefits is a top priority for many of your self-funded employer clients.

Read more: Myth vs. Reality: What Employers Need to Know About Pharmacy Benefits During This Open Enrollment Period

To put it simply, sticking to the status quo isn’t the best option in 2022. Here are three reasons why.

1. Dollars are left on the table.
When employers contract directly with a PBM or integrated insurance company, they often miss out on significant prescription drug savings opportunities. Indeed, PBMs and carriers draw up contracts with their own interests in mind, not those of the employer. Their pricing and reimbursement terms may seem like a bargain, but the nuanced contract language puts employers at a disadvantage. Based on a large volume of contracts our team has assessed, the reality is that most employers don’t get all the discounts and guarantees they expect – and it often costs them around 25% of their spend global pharmaceuticals. With clear and transparent Rx contracts – or at least expertise in understanding the fine print – this pitfall can easily be avoided.

2. Inappropriate medication creates safety and financial risks.
When patients use expensive specialty medications, we assume that the medication and dosage prescribed is appropriate. Unfortunately, this scenario is not always true. Our team of pharmacists has conducted numerous independent studies and found that inappropriate prescriptions account for an additional 7-10% of unnecessary pharmaceutical costs. This is particularly alarming when you consider that specialty drugs can be 12 times more expensive than widely used brand name drugs. Improper prescribing can also pose limb safety risks.

Read more: Perverse incentives: why the health market is motivated to provide expensive and inefficient care

For example, our clinical team discovered an issue with a member taking Gatex for short bowel syndrome. This drug is prescribed on a weight-based regimen, and the drug comes in 5ml or 3.7mg vials; each vial costs more than $40,000. In this case, the doctor’s prescription was based on the weight of the limb, which was supposed to need 3.8mg, so the patient needed two vials per month for the dosage.

However, people with short bowel syndrome may experience weight fluctuations. The clinical team found that the member had, in fact, lost weight – and only one vial was now needed to meet the specific dose requirements of the drug. After contacting the doctor, the prescribed dose was corrected. Optimizing the dose saved the plan $40,000 and ensured the member was taking the correct amount.

3. Service is lacking.
Many employers fear member disruption in what has already been a difficult two years, making them reluctant to change their pharmacy benefits strategy. This is an important consideration. However, current member experience is below average for many employers. Their members are often unable to get prompt answers to their pharmacy questions from the PBM customer service team or the carrier. They are left on hold for long periods of time until they hang up in frustration or leave the pharmacy without their medication, then complain to the HR team.

Read more: For a small business, healthcare savings can be used to attract and retain talent

Making changes to the pharmacy benefits plan or provider will undoubtedly cause disruption, but if it results in a superior service experience and less day-to-day frustration for members, it’s worth looking into. .

As employers face an overheated war for talent, rising costs and other challenges, the stakes are high this year – and it’s important to take a close look at pharmacy benefit plans with a a fresh look in 2022. By taking steps to optimize pharmacy benefits, you-insured customers can reduce prescription drug costs and improve drug safety and service quality for their members throughout the year. future.

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