Some employers have even begun putting each component of the prescription
drug program—retail, mail-order, and
specialty pharmacies and plan administration—out for bidding instead of offering the entire program as a single contract.
“PBMs don’t like to do that,” Bruhnsen
says. “They want a package arrangement” that they can more easily manage
to increase revenue and profitability.
As a general rule, pay close attention
to your relationship with PBMs and specialty pharmacies. “Contracts can be
opaque and sometimes seeded with incentives that cause the vendor to act counter to the best interest of the health plan
and consumers,” Bruhnsen says. “
Contracts have so many moving pieces and
are so complex that you really need to
have a very fine eye to understand all the
nuanced ways that vendors are making
money on these drugs.”
Whatever steps you take to curb costs
and manage utilization, make sure you
clearly explain them to employees. If you
don’t, the chances are significant that
your motives will be misunderstood.
“There are fantastic new opportunities to treat diseases and
conditions that have not existed before,” Bruhnsen says. “But
those opportunities are coming with an enormous cost.” That
is why it is so important for employers to educate employees
about the need to limit expenses while still providing effective
care through strategies like prior authorization, step therapies,
and quantity and supply limits. “People need to understand
that these programs are not there to deny them access,” he says.
And let them know if there is an appeals process that they and
their providers can use to argue for the medical necessity of a
Also help workers understand that the medications they
see advertised on television aren’t necessarily superior to the
ones that aren’t. “The goal should be more evidence-based and
less marketing-based prescription drug usage or asking for one
drug or another,” Kushner says. If patients ask for a specific
brand, providers may write a prescription for that drug just to
keep them happy. “There is no penalty for doing that,” he says.
“Employers need to do a better job of educating employees on
the best way to use the prescription drug plan.”
That’s a message you need to communicate often. “Use a
variety of media, traditional and electronic, to come at them
from different angles,” says De La Torre. “Give them the tools to
make cost-effective decisions” based on appropriate treatment
options. For example, when emphasizing the use of generics,
cite studies of the effectiveness of these drugs rather than simply
stating that the medications are less expensive.
Mind the Big Picture
While managing prescription drug costs is and will continue to
be a critical goal for the next several years at least, plan sponsors
must keep their cost-management efforts in line with the larger
picture of promoting employee health and well-being. The right
medication for the right patient in the right dosage and with
the right follow-up care can make a world of difference for an
individual with a chronic or acute condition.
That, in turn, can yield benefits to the employer. “If an
employee with multiple sclerosis takes a specialty drug and it
works, that individual will be a more productive worker and
for longer,” Sondergeld says.
At the same time, make sure your company’s prescription
drug program is accessible, understandable and affordable for
beneficiaries. The last thing you want to do is make it more dif-
ficult for workers and their families to get the treatments they
need. “The worst outcome is when people take very expensive
drugs and don’t adhere to the regimen and don’t get better,”
Thompson says. “That is a true waste.”
Joanne Sammer is a New Jersey-based business and financial writer.
6 Ways to Manage Specialty Rx Costs
1. Require prior authorization for these drugs.
2. Implement step therapies that require patients to try less expensive medications before moving on to more-expensive specialty drugs.
3. Contract with a specialty pharmacy to manage the use of the drugs and
provide some level of care management. These pharmacies also often have
lower dispensing fees for these medications and may offer better discounts.
4. Create a dedicated tier for specialty drugs in the prescription program.
5. Leverage case management services provided by health plans and specialty pharmacies to manage complex drug regimens and provide patient
support. Given the potential for side effects and the high cost of many specialty drugs, it is important that people take these medications correctly and
complete the regimen.
6. Make sure drugs are administered in the lowest-cost and most-effective
health care setting. This is particularly important for medications that must be
infused or injected under the supervision of a health care provider.