Controlling RX Spend

Employers are concerned about what the AHCA will do to their premiums, benefit plan structure, compliance procedures, and more, but many can benefit by having a concentrated look at what they can be doing to address their current costs. Pharmacy, in particular, can be responsible for up to 30% of claims costs, and yet it is often overlooked as an area of potential savings. Of course, employers would like their staff to have access to the medications that they need, but it is also imperative to focus on ensuring this spend category is well-managed and that costs are kept in check while ensuring staff obtain what they need to maintain their health. 

  • Know your numbers: By analyzing what percentage of your prescription drugs are in the various tiers of generic, preferred and non-preferred brand, and specialty/injectable medicines, an employer gets a better idea of where their dollars are going and where to focus concerted efforts. It may come as no surprise that the dollars allocated to each tier may be largely the same. Because specialty medications are so much more costly, one specialty medicine per month may equate to 20 generics being filled. Identifying your expenses is the first step to cost-optimization. 
  • Employee education: Even if information about your dispense rates and percentages is not made available by your health plan, educating the staff is an easy and effective way to ensure they are aware of the most cost-effective ways to obtain the medicines they take on a regular basis. 
    • Preferred pharmacies
    • Mail order
    • Discount programs (GoodRX may be cheaper for specific medications versus having insurance filed, for example)
    • Considering generics
  • Specialty drug focus: For those members that require specialty medications, it may make sense to have them in touch with a case manager to help them manage their condition in the most cost-effective way. Many pharmacy benefit managers have dedicated pharmacists that can help work through issues with their higher utilizing members. Designated pharmacy care may also provide a more hands-on and direct regimen of care for the covered member, which can help them live a healthier life. 

There are many ways to combat ever-increasing costs for specialty medications in your population. 

Niko Caparisos