Wouldn’t it be great if you could secure cost-effective health benefits for employees that also reduce their prescription drug costs?
Stop laughing, a new report says it’s doable!
Prices at the gas pumps are skyrocketing. And economic experts say that due to the boycott of everything going in and coming out of Russia, groceries are going to go up as is just about everything else. So, employees will be looking to cut corners where they can.
One of those corners is often prescription drugs. Medications are expensive, and employees often see them as an easy way to save a dollar here and there. Maybe they start cutting pills in half or take one every other day, or worst of all, just skip taking them altogether.
That doesn’t bode well for your healthcare expenses. When employees skip medications, their conditions usually worsen, and they miss work. That translates to more doctor visits and more expensive treatments to get their illnesses back under control.
So, cutting corners on medications is the last thing your company should want employees to do.
How Benefit pros can help
How can you help employees, so they don’t cut medication corners?
First off, watch out for utilization management (UM). It’s touted as being able to save money and provide better health care. But according to CancerCare’s “The Employers’ Prescription for Employee Protection Toolkit” it can negatively impact healthcare outcomes. This rings especially true for patients with cancer and other serious illnesses. Because as the cost to treat the illness rises, so does UM due to monitoring treatment and spending.
“Many cost-saving practices seem benign but can cause great harm, particularly to those with serious or chronic health conditions,” said Patricia J. Goldsmith, Chief Executive Officer, CancerCare. “Insurance plan restrictions often prevent patients from accessing the medications they desperately need, which in turn, can have a critical impact on employee wellbeing and productivity.”
The 62-page guide provides Benefits pros insight into how they can effectively provide health benefits that reduce prescription drug costs and lower the barriers that jeopardize employee healthcare outcomes.
Improve design of prescription plan
The one we’re focusing on here is improving the design of prescription benefit programs for employees.
The first thing you want to do is avoid closed formularies. They limit employees’ access to medications because they exclude certain drugs.
Second, don’t use discriminatory metrics when creating a formulary or assigning drugs to tiers. When you base your value assessment on “quality-adjusted life year,” it gives a generic measure of the disease burden to assess the value of a medical intervention.
Third, only make formulary changes at the beginning of the plan year and give plan participants plenty of notice. This way they can use open enrollment to change plans to a more suitable one if so desired. Also, making changes mid-year can lead to all kinds of issues like noncompliance, adverse reactions, increased costs and a loss of confidence in you by plan participants.
Fourth, for newly approved drugs, don’t have absolute “exclude at launch” policies. You never know if these breakthrough treatments will change the standard of care, and you don’t want to keep your plan participants from them.
Fifth, if a patient has coverage for a medication that has stabilized their condition, don’t limit or exclude it during the plan year.
Finally, cost-sharing arrangements can impact certain patients, like those with cancer, because it places all or most of the medications on the highest cost-sharing tier. So, don’t do it.
Positive steps to take
Prescription benefit programs should be patient-centered and be based on evidence-based standards of care. Your best bet is to implement an open formulary. It allows for the use and coverage of FDA-approved drugs when medically necessary.
The more you can do to lower out-of-pocket costs for patients with chronic conditions, the better. High costs impede patient adherence which leads to poorer health and higher benefit costs for the employer. CancerCare’s toolkit suggests offering a copay-only plan option for prescription meds.
It’s also a good idea to provide coverage for off-label drugs and biologics, if they’re backed up by evidence and expert consensus.
When it comes to formulary exceptions and appeals, you should require expert reviewers. This would be a physician in the same or similar specialty that manages the condition or treatment.
Also, make sure that all or most rebates are passed on to your plan participants to lower out-of-pocket costs.