It’s Time to Consider Regenerating Your Pharmacy Benefit Program
9 Key Considerations
The unexpected and rapid spread of COVID-19 is having significant impact on many industries, including Pharmacy Benefit Management. While this time of uncertainty has forced many companies to furlough or even terminate staff, employees are still filling prescriptions and starting new treatments.
As a result, PBMs have moved quickly to develop new strategies and policies, but what will these changes mean for plan sponsor costs and drug trend?
Now is the time to address these questions and potential impact on plan costs, pricing, utilization and member trends moving forward. As the COVID-19 situation continues to evolve, it is crucial to ensure your pharmacy benefit program is reviewed, refreshed and optimally managed as pharmacy benefit savings are more important than ever.
Below are nine key considerations in regenerating and streamlining your pharmacy benefit program to help support the financial health of your company.
- PBM contract review – Conduct an independent, unbiased review. If you recently signed a new PBM contract or have been on a contract for some time, there could be membership thresholds that are tied to your pricing. Due to COVID-19’s unexpected staff reductions or furloughs, modeling of these impacts is crucial to understanding the financial exposure now and, in the future, if your discounts and rebates are at risk of being reduced.
- Perform a market check or PBM RFP. To ensure your PBM pricing is optimal, it’s important to perform periodic market checks. PBM pricing changes rapidly, and this is an area that could bring substantial savings to your plan.
- Comprehensive, strategic review of your current plan design and management programs. A comprehensive review of your plan design, trend management programs and clinical programs can identify savings opportunities for your plan. It is important to periodically assess all aspects of your plan to identify areas for improvement.
- Identify specialty pharmacy management opportunities. Specialty pharmacy optimization is a critical area of your pharmacy benefit plan. Understanding your entire specialty spend and patterns across pharmacy and medical benefits is key to identifying effective strategies to manage specialty and provide actionable savings opportunities. Being aware of the specialty pipeline and future cost impact to your plan is also important.
- PBM audit. On-going oversight and monitoring of your prescription data is a key factor in truly managing your pharmacy benefit. Some of the key areas that are important to audit include financial metrics, rebates, specialty pharmacy, days’ supply, pharmacy channel and more.
- Assess your plan’s COVID-19 risk. As the country begins re-entering the general work force, understanding your COVID-19 risk can help define your path moving forward and support your decision-making process. Using client specific data and specified criteria, you can identify vulnerable populations, potential cost impact, and identify new at-risk members as they occur.
- Re-assess plan policies. Due to COVID-19, many PBMs temporarily changed their policies to accommodate access to medications as well to reduce administrative burdens on physician offices. Below are some policies that should be reviewed and monitored.
- Refill-too-soon policies have been waived by many PBMs to allow members with chronic conditions to continually receive their medications. Stockpiling has been a concern with this policy change.
- PBMs have updated policies to allow extended prior authorizations for medications previously approved, providing an additional 60 to 90-day period for the authorization.
- Quantity Level Limit (QLL) changes have occurred to manage critical drugs considered for COVID-19 treatment and to ensure adequate supplies are maintained for patients with conditions including asthma, lupus, rheumatoid arthritis and HIV.
- Days Supply Extensions have been implemented to allow patients to receive greater than a 30-day supply. Extending days’ supply can increase plan costs.
- Copay overrides are allowing members to access non-preferred medications if the preferred is impacted by a shortage which could impact both drug spend and rebates.
- Mail order transitions – migrating members to mail order pharmacy
While these changes have been an important part of providing access to critical medications, they will also impact costs. Plans are encouraged to assess these policies, monitor potential abuse, quantify the financial impact and ensure original parameters are restored at the appropriate time.
- Early identification of clinical management opportunities. For plans that have the capability to identify clinical opportunities in a timely manner, they should intervene on costly or complex medications as appropriate to achieve significant savings and improve outcomes.
- Offer a prescription discount card – For employers with part-time employees or employees that are no longer eligible for insurance benefits, there are several prescription discount card programs available in the market, providing access to affordable medications. Look for a discount card that has been vetted and is focused on providing significant prescription drug discounts for those that are uninsured or underinsured.
We understand plans have questions and are concerned; and because things are rapidly changing, it is important that you avoid making decisions or changes without careful consideration. It is recommended that you reach out to a trusted consultant with pharmacy benefits expertise to guide you through the details and do the technical work so you can focus on your business and your membership.
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