Maintaining the health of your employees requires sourcing high-cost pharmaceuticals (i.e. specialty medications) and related supplies in a way that is cost effective while maintaining quality and accessibility.

To understand about how to lower the overall pharmacy cost of your program, we first need to understand a little about what a specialty medication is.

What is a Specialty Medication?

A specialty medication is used to a treat complex, chronic medical condition such as rheumatoid arthritis, Crohn’s disease, multiple sclerosis, or cancer. Drugs in this medication class often cost more than standard medications, from hundreds to hundreds of thousands of dollars.

The Problem

Specialty drugs or pharmaceuticals could substantially drive costs up to unbearable levels for your health plan. Overall, pharmacy spend is quickly becoming one of the major cost drivers of health plans just like yours. The key to making an impact on the cost of these medications is to understand and determine what your prescription benefit should cover and to involve cost containment measures as close as possible to the prescriber writing the prescription and the process the member goes through filling the prescription (i.e. workflow).

Specialty drugs are commonplace today, so much so that this class of medications is driving most of the pharmacy spend for health plans in the US. To provide a sense of this trend, according to the Congressional Budget Office, “…nationwide spending of prescription drugs increased from $30 billion in 1980 to $335 billion in 2018.” [1]

How can we balance the needs of plan members with the need for a sustainable employee benefit plan? The answer is a simple three-step process!

Triggers, Sourcing, and Member Engagement & Education

Members are a stakeholder in your employee benefit plan and need to diligently work with the plan to keep your plan affordable and sustainable. Members that refuse to work with the plan will needlessly drive up the plan cost. As a result, the plan sponsor needs to decide what measures need to be put into place to encourage plan members to work with the plan (i.e. steerage, mandates, penalties, etc.).

Without member inclusion and engagement, the plan costs will eventually drive-up plan members’ premiums to the point it may no longer be affordable. When this happens, the plan sponsor loses the ability to have an affordable major medical program to recruit and retain quality employees.

 

The plan sponsor can take three (3) steps to help pharmaceuticals remain affordable to the plan.

Step 1

Trigger. Establish a trigger within the prescription filling process (i.e., workflow) that notifies the plan when a high-dollar medication is about to be filled. The plan sponsor needs to determine at what dollar value to set as their trigger.

Step 2

Sourcing. The plan needs to have a legitimate alternate source to fill this class of medications. The ability to access this source needs to be embedded within the prescription filling workflow to mitigate savings gaps.

Step 3

Member Engagement and Education. Needless to say, it’s difficult to educate a plan member about all the facets of the employee benefit plan at open enrollment. Members quickly forget much of the information conveyed as soon as they leave the benefits meeting. Sometimes the amount of information provided is overwhelming. The plan must have a member engagement outreach once the trigger (i.e. Step 1) has been occurred. This engagement should be made by competent medical personnel that understand what the member is going through and can help the member secure the medication they need at an affordable price.

All three (3) of the steps mentioned above must be fully embedded within the plan’s workflow. Having a great source for lower cost medications and a supreme engagement process is meaningless unless the plan has an automated trigger built within the workflow to identify these medications as they are being prescribed and filled (and vice versa).

At GBS, we know finding ways to keep plan costs down could mean the difference between a company being able to offer said plan and not being able to. By working together with plan members and the plan sponsor using fully embedded tools, we can help costs remain low and keep your health plan sustainable.

[1] Congressional Budget Office, “Prescription Drugs: Spending, Use, and Prices.” January 2022. Source URL: https://www.cbo.gov/system/files/2022-01/57050-Rx-Spending.pdf