When you are delivering a prescription benefit, it’s essential to maintain clinical value as the standard. Everything has to be done on the basis of clinical. Prescription drug manufacturers have a clinical orientation so that their drugs get approved by the U.S. Food and Drug Administration (FDA), and they promote the clinical value of their medications. Pharmacy Benefit Managers (PBMs) have drug formularies, and those are designed around clinical value as well.
Drug formularies are not always designed through the manufacturer or PBM to focus on the economic value. So we find ourselves in a situation sometimes where we see multiple choices for a medication – and some have a better clinical and economic profile than others. When that’s the case, we have to put something into place that is going to help steer people toward that clinically and economically valuable medication.
Focusing on the High-Cost Claims
Because of the mix in medications now, if you look at 90%-95% of our prescriptions, they are generic or very low-cost brand drugs – and they represent about 10% of costs. If you look at that other 5%-10%, those are the higher-cost brands, typically over $1,000, as well as specialty medications. Roughly 2% of the members will for 50%-60% of the costs of any given plan. As we think about what we could do to help reduce costs, our emphasis is on those claims that are on the high-end of the brand category and on the specialty category.
Managing Member Disruption
The intent is not to create disruption but to make sure that we are redirecting wherever appropriate. For example, if somebody is using a drug off-label, the goal is to steer them to an alternative approach. If somebody is using a more expensive brand just because it’s a new combination that’s being marketed and there are less expensive products on the market, the goal is to redirect those. When you do this, you are creating some interruption on the member experience. Someone may go to the pharmacy to get a low clinical value drug, like Duexis®, and the claim is going to reject because there are reasonable alternatives for a fraction of the cost. Duexis, for example, costs $2,600 whereas the over-the-counter equivalents Advil® and Pepcid® cost about $20.
Most of the time, the physician will write a new prescription for a medication that is less expensive. A lot of the demand for these high-cost, low clinical value drugs is based on coupons that are promoted by pharmaceutical manufacturers through the physician’s office. A good example of this is someone who has acne and is looking to take a newer, more expensive medication in the range of $1,200, and they get redirected back to a less expensive brand-name drug that costs $400.
Balancing Clinical & Economic Value
When physicians make a request for a prior authorization (PA), we are looking for documentation and chart notes to support the diagnosis, dosing, and any other specific criteria that the drug might carry. (Most PBMs don’t do this; they will accept verbal information and don’t get as much to consider in the PA process.) In most cases, patients are redirected to a drug that is more clinically appropriate at a lower cost, and perhaps an empiric therapy that they would start at before moving to a more advanced therapy.
We respect that this does create some disruption among members, but the goal is to try to impact as few members as possible while delivering substantial savings to a plan. With 2% of the members driving up to 60% of the cost, you can see where we’re touching a fairly small amount of the membership, but savings from these clinical management programs can net 7%-10% or even more depending on the circumstances.
As a Pharmacy Benefits Optimizer (PBO), we believe it’s a matter of evaluating the value of doing or not doing something that is clinically and economically sound – and finding the right balance for the pharmacy benefits plan.
To learn more about how strategies like these can help your clients achieve their pharmacy benefits cost and clinical goals, check out our free e-book, Building an Optimized Clinical Playbook.