How to Map Your Pharmacy Benefit for Optimal Results

Top 3 Things You’ll Learn

  1. Key considerations for planning your pharmacy roadmap
  2. How to balance cost and clinical quality
  3. How to actively engage in managing your pharmacy benefit

Did you know that specialty drug claims are driving over 40% of pharmacy drug plan costs? With more high-cost specialty drugs coming to market each year, specialty drug spend will only escalate. As an employer, you may end up paying too much for your pharmacy benefit, and the costs may become unmanageable. That’s why you need a sound pharmacy roadmap to address the cost drivers that can be managed.

Map Out Your Pharmacy Journey

To manage pharmacy feasibly, you must find the balance between cost and clinical quality. Luckily there are tools available to you that can be used to determine your ideal path to keeping pharmacy benefits affordable. However, without a firm grasp of the road ahead, it’s hard to get on the path to where you want to be.

Actively managing your pharmacy spend means finding the balance between appropriate cost and clinical quality. #KeepRxAffordable

Creating an optimal pharmacy roadmap begins with three basic considerations:

  1. Know Where You’ve Been: Look back at the previous year to evaluate the successes and challenges you faced. For most employers, this is most easily identified by evaluating pricing and contract terms, and how those components have been positively or negatively impacting your budget. For those with clinical programs already in place, knowing how those have impacted your plan and members economically is necessary to have handy.
  2. Know Where You Are: Look at your current claims data to understand the specific numbers now. Note: this may be harder to discern if you don’t have access to detailed analytics. You’ll want to know what specific factors are driving your drug trend, particularly risk areas that are contributing to unnecessary spending. This requires visibility into how much you are spending on off-label prescribing, high-cost drugs with questionable clinical value and those with lower-cost alternatives, prescriptions filled with inappropriate dosing, etc. Evaluating how your plan is impacted by these controllable risk areas provides a framework for knowing the clinical cost-saving opportunities available to you.
  3. Know Where You Want to Be: Look at your clinical cost-saving opportunities and your current plan spend to determine your ideal destination. To do this, combine your findings from the first two steps then decide on your desired savings goal. Once your goal is identified, the appropriate clinical solutions can be put in place to change your plan’s current trajectory and help you reach that desired destination.

Bottom Line…

As an employer, you want to be in control of deciding how much or how little to steer your plan to ensure a balance of cost-savings with member impact. Just as a car can spin out of control by making a sharp turn while driving too fast, you need to make sure you are heading toward the desired results without causing too much member disruption. By starting small with foundational clinical solutions, you can take slight turns along the trend trajectory to get to where you want to be.

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