How to Map Your Pharmacy Benefit for Optimal Results

Top 3 Things You’ll Learn

  1. Key considerations for planning your pharmacy benefit plan design roadmap
  2. How to balance prescription drug costs and clinical appropriateness in employer-sponsored pharmacy plans
  3. Three steps to actively engage in managing your pharmacy benefit plan using data analytics

Did you know that specialty medication claims are driving over 40% of pharmacy drug plan costs? With more high-cost specialty drugs coming to market each year, your clients’ prescription drug spending will only escalate. Your self-funded employer clients may be end up paying too much for their pharmacy benefit, and the costs may become unmanageable. That’s why they need a sound roadmap, rooted in data analytics, to address the prescription drug cost drivers that can be managed.

Map Out Your Pharmacy Journey

To manage pharmacy benefit costs, it’s important that you help your clients. Luckily there are data-driven tools available to you that can be used to determine the ideal path to keeping your clients’ pharmacy benefits affordable. Doing so requires a firm grasp of the road ahead, so that you can get your clients on the path to where you want them to be.

Specialty medication claims are driving over 40% of pharmacy drug plan costs. Actively managing your pharmacy spend means finding the balance between appropriate cost and clinical quality. #KeepRxAffordable

Creating the optimal pharmacy benefit cost-management strategy begins with three basic considerations:

  1. Know Where You’ve Been: Look back at the previous year’s pharmacy plan data to evaluate the successes and challenges your clients faced. For most employer clients, 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 management programs already in place, having detailed data showing how those have impacted the plan and its members economically is necessary.
  2. Know Where You Are: Look at your clients’ current claims data to understand the current utilization and spend. Note: this may be harder to discern if you don’t have access to detailed analytics for your clients. You’ll want to know what specific factors are driving their prescription drug trend, particularly risk areas that are contributing to unnecessary or inappropriate spending. This requires visibility into how much they are spending on off-label prescribing, high-cost drugs with questionable clinical value and lower-cost alternatives, inappropriate dosing, etc. Evaluating how your clients’ pharmacy plan is impacted by these controllable risk areas provides a framework for identifying potential cost-saving clinical management opportunities.
  3. Know Where You Want to Be: Look at the clinical opportunities and current plan spend to determine the goal for their pharmacy plan, in other words the ideal destination. To do this, combine your findings from the first two steps then decide on your desired prescription drug savings objective. Once your goal is identified, the appropriate clinical solutions can be put in place to change your clients’ current trajectory and help them reach that desired destination.

Bottom Line…

Employers want to be in control of deciding how much or how little to steer their pharmacy benefit plan to ensure a balance of cost-savings and 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 your clients are using a data-driven approach toward their desired results without causing an undesired level of member disruption. By starting small with foundational cost and utilization management solutions, your clients can take slight turns along the trend trajectory to get where they want to be.

To learn more about applying data-driven clinical management strategies to your clients’ pharmacy benefit plans, check out our Clinical Strategies Playbook.

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