2009 Drug Trend Insights - Prime Therapeutics

Specialty Drug ManagementOUR INSIGHTS1 in 5 — Members Who Don’t Fill Specialty Prescriptions When Out-Of-Pocket Costs Are Too High Multiple sclerosis pharmacy productshave typical average wholesale prices of $2,200 per month supply. One result of high prices has been a substantial increase in the out-of-pocketcost for members. We analyzed the patterns of 7.3 million commercial members to determine if a relationship exists between out-of-pocketcosts and members declining to fill their prescription. We found that one in five members with an out-of-pocket cost greater than $250 declinedto fill and they were seven times more likely to decline to fill than members with costs of $100 or less. 53 Plan sponsors should consider membercost-share impact when designing pharmacy benefits. Our recommendation is to include a $100 monthly out-of-pocket maximum in Specialtybenefit plan designs.Key Metrics for Specialty DrugsSome plan sponsors have respondedto the high cost of Specialty drugsby increasing the portion of costsmembers are expected to pay. Butshifting more costs to memberscan create a barrier to consistentmedication use. Instead, weadvocate an approach that limitsthe out-of-pocket burden to supportadherence. Keep costs low throughstrong network management andefficient delivery channels.Progress toward these goals ismonitored through three keymetrics: adherence, formularycompliance and effective discounts.How plan sponsors can partner withus to impact each of these metricsis discussed in the pages that follow.Managing Specialty Drug SpendIn managing Specialty drugs,concentrate on:+ Designing benefit plans withcosts in mindOur research shows that high outof-pocketcosts cause members toskip filling their Specialty drugprescriptions. Plan designs shouldinclude out-of-pocket maximumsto help keep treatment affordable.Retain a tiered design to driveuse of the lowest-cost optionwhenever one is available.Fig 31 Tools to manage specialty drugsDesignEncourage+ Optimal plan design+ Formulary management+ Retail lock-out+ Physician buy-and-bill guidelines+ Care management+ Targeted adherence outreach+ Encouraging therapy adherenceSpecialty care managersmonitor side effects, answerquestions and help membersfeel supported — activities thatoptimize therapy and improveadherence.+ Managing delivery channelsto control costsUsing an exclusive Specialtynetwork streamlinesadministration and ensures thelowest net cost. Our Specialtypharmacy program, Triessent ® ,offers aggressive discounts thatsave money for plan sponsorsand members.Manage+ Utilization management52 Connect ● Create