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

Top 3 Things You’ll Learn

  1. Projected prescription drug spending in the U.S.
  2. How the rise of expensive specialty drugs is impacting pharmacy benefits costs
  3. Four key strategies for self-funded employers to manage 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.

Like most employers, when new therapies hit the market, your clients likely worry about how the cost of those medications will affect their already-strapped healthcare benefits budget. But did you know the reality for most self-funded 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 your clients 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 an independent, pharmacist-led review process to ensure that members meet the approved criteria for receiving the medication being prescribed. Sometimes a thorough review of the member’s health records can show that an alternative therapy is lower in cost and still clinically appropriate, despite the prescriber’s best intentions.
  2. Optimize the dose. Many high-cost drug claims are either parity priced (same price for all strengths) or weight based, presenting an opportunity for clinical intervention to switch the member to a more appropriate dose of the medication. 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 to confirm the member is staying adherent to the medication and to address any concerns that may arise. Patients conditions can change over time and so can their response to therapy. For the benefit of the member and your clients’ pharmacy benefits, establish a communication plan to manage their case and make medication adjustments as needed. This can be accomplished with a PBM or pharmacy benefits optimizer who offers these services.

Check out our case studies to see real-life examples of how employers used these strategies to lower their pharmacy benefits costs.

Source: America’s Health Insurance Plans

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