2009 Drug Trend Insights - Prime Therapeutics

Strategic approach to category trendsPLAN DESIGN INSIGHTS: Optimal Plan Design for Focus DrugsDesigned for ValuePlan designs may be structured toreflect a commitment to removingbarriers to adherence. Today, plansoften referred to as “value-basedbenefit designs” are gaining muchpopular press. These plans reducemember out-of-pocket costs with thegoal of encouraging drug adherence.Supporting adherence is criticallyimportant. However, researchershave not definitively establisheda connection between reducedout-of-pocket costs and improvedadherence. Indeed, our analysisalso reveals that below a certainthreshold, drugs may be overused.As a result, we do not recommendeliminating copays entirely. Instead,we advocate retaining meaningfulcost-sharing to keep membersengaged and targeting at-riskmembers through a member-levelapproach to benefits.In our view, true “value-based”benefit design includes the followingcomponents:+ Alignment with corporate healthand wellness initiatives+ Regular communication withmembers through multiplechannels+ Benefit plan designs in tune withbroader plan sponsor goals+ Member-level benefit designsthat connect coverage levels topredetermined factorsThere are several approaches to structuring benefit plan designs to maximize the value of pharmacy spending.Options can be categorized into three types:Plan Type Provides financial incentive to improve adherence for… Plan CostMembersImpacted1) Drug-based…all members using drugs in a category where drug therapyhas been shown to decrease the risk of an adverse medical eventHighAll2) Behavior-based...all members demonstrating a predefined behavior, such asparticipation in a condition management programMediumSome3) Risk-based * …members at the highest risk for an adverse medical outcome Low Fewest*We recommend risk-based benefit design because it is the most focused approach. Different from standard valuebasedbenefit designs, only members at high risk for an adverse medical event are targeted. Plan sponsors minimizecosts and maximize efficiency by easing the cost burden for those who will benefit most. This focused approachoffers the greatest return on pharmacy spend.© Prime Therapeutics 2009 Drug Trend Insights43