The increasing percentage of plan dollars allocated to pharmacy benefits has driven plan sponsors to seek ways to optimize the value of their spend. By better managing pharmacy benefits, plans sponsors can achieve cost efficiencies both inside and outside of the PBM structure. Faced with increasing costs and a dissatisfied employee population, a well-known Mid-Atlantic food manufacturer engaged ELMCRx Solutions to help rethink their prescription drug plan.
This group’s demographics are consistent with many mid-sized self-funded employers.
- 2,500 lives
- $2.2 million in annual drug
- Statistically normal age/sex
- Fixed Copays representing 18% of total Rx
- Optum contract with two contract re-negotiations
- Plan Spend is 60% Specialty Rx and 89% Generic Fill Rate (GFR)
BY RECONFIGURING THE RX PLAN, THE COMPANY HAS MAINTAINED A FLAT ANNUAL PHARMACY SPEND.
ELMCRx reconfigured the company’s plan and implemented several recommended prescription drug risk management programs in 2012. Since implementing these programs, the plan has successfully managed to hold its annual pharmacy benefit spending flat, resulting in a savings of more than 90% since implementation. Additionally, the plan has successfully eliminated the 7 percent annual industry average pharmacy benefit trend increases. Three successful contract renegotiations contributed 17% of the total savings while the remaining 70% of the annual cost savings has been derived from:
- Outsourced Specialty Pharmacy Clinical Prior Authorizations
- Outsourced Lowest Net Cost Non-Specialty Drug Program
- Outsourced Specialty Alternate Funding Program
- Outsourced Diabetic Monitor and Supplies Program
- Annual PBM Contract Pricing Guarantee Compliance Audits
- Moving J Code medications from medical to pharmacy
- Limits and elimination of Mail Order Auto Refill a net increase in Rx benefit costs, but a net decrease in overall plan costs)
- Elimination of Low Clinical Value Drugs Coverage
- Proper Quantity Limits, Refill-too-Soon Limits, Dose and Duration
Because program management is never-ending, the current year strategic Initiatives include migration to home infusion services, Specialty Drugs Telehealth, J Code Member Co-pay Assistance, and J Code Rebates.
CALL OUT NOTE
By reconfiguring the Rx plan, the company has maintained a flat annual pharmacy spend.
