High-Cost Rx Claims Are on the Rise: Are You Prepared?

Top 3 Things You’ll Learn

  1. Projected prescription drug spending in 2020
  2. Major factors driving high pharmacy benefit plan costs
  3. Our recommended strategy for managing high-cost Rx claims

In 2016, America’s Health Insurance Plans (AHIP) reported that prescription spending in the United States was $337 billion in 2015. They projected that by 2020, U.S.-based spending would hit $560 billion. That’s a 66% increase over five years.

If you’re like most employers, when new therapies hit the market, you worry about how the cost of those medications will affect your already strapped budget. But did you know the reality for most employers is that just 1% of their members are already driving 40%, 50%, or more of plan costs?

Some analysts point to the cost of generics and brand name medications as a reason for the increased spending. Others believe that the number of prescriptions per person may play a role. While those factors are concerning, the major influence is the increasing number of specialty medications and the associated cost.

One strategy to help offset the cost of some of the expensive therapies is to ensure proper use of the more commonly used generics when appropriate. However, it is important that you have a consistent process in place to monitor and review high-cost prescription claims to ensure you are not overpaying on unnecessary medications.

The reality for most employers is that just 1% of their members are driving 40% or more of Rx benefit costs. Are you prepared? #drugcosts

Our recommended approach to high-cost pharmacy claims:

  1. Implement a review process to ensure that the member meets the approved criteria for receiving the medication. Sometimes a thorough review of the member’s health records can show that an alternative therapy is warranted, despite the prescriber’s best intentions.
  2. Optimize the dose. Many high-cost claims are either parity priced (same price for all strengths) or weight based. For example, four individual 1mg Pomalyst tablets can cost four times more than just one 4mg tablet. Switching the member’s dosing can save as much as $720K over 12 months of therapy.
  3. Review the claim with your Stop Loss Carrier early to validate coverage.
  4. Follow the case with regular touch points. Patients conditions can change and so can their response to therapy. For the benefit of the member and your plan, establish a communication plan to manage their case and make medication adjustments as needed.

Source: America’s Health Insurance Plans

Share It