Pharmacy benefits plans have the potential to play an important role in the health and well-being of plan participants, if the plans are designed appropriately. Otherwise, they can be a growing drain on employer budgets. This series has looked at a number of potentially costly developments in the pharmacy benefits arena – the expiration of patents, poor therapy adherence by plan members, the consolidation of the pharmacy benefit manager (PBM) marketplace, and the emergence of biotechnology drugs – and presented some strategies employers can use to effectively manage those challenges.
To have a positive impact on the health and well-being of participants, those strategies must actively manage the pharmacy benefit so that members have access to quality drug therapy and, at the same time, ensure drug safety, eliminate waste and achieve appropriate usage. Key elements of this strategy include:
- Financial incentives for members to use low-cost generic drugs and formulary brand drugs
- Clinical management rules, such as prior authorization and step therapy, to ensure appropriate usage and help improve drug compliance
- Drug channel management to ensure that acute-care, maintenance and specialty drugs are dispensed through the most cost-effective and efficient pharmacy delivery channel — retail, mail order or specialty pharmacy
- Aggressive negotiation of financial and non-financial contract terms to capitalize on today’s buyer’s market for PBM services
- Specialty drug carve-out and proactive clinical management programs to ensure optimum pricing, appropriate usage and avoidance of high-cost hospitalizations that drive up medical plan costs
Marketplace forces at play create challenges for plan sponsors to manage their pharmacy benefits plans effectively. These forces also present savings opportunities for employers, provided realistic strategies are developed and implemented effectively.
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