Pharmacy benefit managers like to talk about specialty drugs, and for good reason. They’re the fastest growing segment of employers’ health plan costs. With the aid of a PBM, an employer likely already knows their organization’s specialty spend, specialty trend and top specialty drugs. They may even have been offered a glimpse into the specialty drug pipeline and know what new drugs are on their way to market.
But, despite all the talk of specialty drugs, many employers don't know what their PBMs are doing today to actually manage their specialty drug programs. For example, do your clients know which drugs and drug categories require prior authorization? Do they agree with the PBM’s decisions about these drugs?
Also see: "5 ways to help manage specialty drug spending."
A laundry list of specialty drug management strategies are possible, so it's important to ask three questions about any strategy an employer is considering:
1) Is the PBM already doing this today for the plan?
2) If it's not, is the PBM capable of doing it?
3) If they can do it, does it make sense for the plan?
We tend to talk a lot about questions two and three, but surprisingly many times employers aren't aware of what's already going on (or not going on) behind the scenes.
Putting it into practice
Here’s an example of how these questions can be helpful. Consider the policy of split first fills for oral oncology medications. This refers to sending a shorter supply to a patient the first time he or she tries an oral oncology medication to determine tolerance, rather than sending a full 30-day supply. This approach can reduce waste if the drug is not well tolerated. If you ask the three questions noted above, you’ll understand why they’re all important:
1) Not all plans do this today.
2) Not all PBMs can administer it.
3) For many employers, this strategy may make sense.
Employers need clear, up-front advice on how to proactively manage their specialty pharmacy programs. They need an independent adviser — one who can shine a light on PBM practices and offer data-driven decision-making capabilities.
Martin is vice president and senior actuarial consultant for Lockton Benefit Group. Lockton employee benefit clients rely on her pharmacy analytics expertise and ability to always ask the right questions to make smart decisions about their pharmacy benefit programs. Reach her at (816) 751-2110 or email@example.com.
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