It's hard to miss the growing popularity of Ozempic, prescribed off-label for weight loss. Paying extra attention to the PBM contract is important if you are a self-funded Plan Sponsor or Benefit Consultant.
A newer class of diabetes therapy drugs, like Ozempic, averaging $1,000 per month, is becoming an unprecedented challenge to PBMs and Plan Sponsors. Does your PBM plan have the appropriate utilization management in place?
Ozempic has strong brand awareness, with a well-known commercial jingle, and is a very effective medication for type 2 diabetes. However, most PBMs require step therapy, and most patients with Type 2 are not immediately prescribed Ozempic. In many cases, they start with Metformin, considered the gold standard.
If you are a Benefit Advisor or Plan Sponsor of a self-funded plan, you might wonder how your current PBM will mitigate this new health trend. Your organization's demographics play a large role in aligning your cost-containment strategies and pharmacy benefit plan design. Is your current PBM focused on your organization's needs? Are they prepared to provide oversight and clinical guidance?
Here are some other important questions to ask about your current PBM contract:
Does the plan have or allow for coverage policies and requirements such as Prior Authorizations, Step Therapy, and Quantity Limits?
Does the PBM provide Monitoring and Reporting to track utilization and cost trends?
Is the PBM contract flexible to allow Cost Containment Strategies so the sponsor can better manage the plan's overall spending?
In some cases, it may be necessary to implement a standard exclusion for all weight loss products. Mounjaro, Eli Lily's weight loss drug, is awaiting FDA approval and is set to be a blockbuster brand ready to compete with Ozempic's market share.
Contact an APC Pharmacy Benefit Consultant to discuss how we can help identify the highest-cost drugs and evaluate your self-funded health plan's trends and patterns in utilization. APC can evaluate the effectiveness of your plan design and benchmark it against industry standards to provide valuable insights to help with cost-saving decisions.
One medical claim can increase your self-funded plan renewal and how to offset using Rx cost containment strategies.
When a self-funded health plan incurs large ongoing medical claims, they rely on stop-loss coverage to mitigate this risk. However, many stop-loss plans can set individual-specific deductibles for higher-risk members. This practice, called lasering, can negatively impact a growing business's cash flow and cause increases in plan renewal costs.
Specialty drug spending currently accounts for over 50% of net spending in pharma. These brands are priced excessively high at $200+ per month.
When trying to mitigate potential stop-loss risk exposure to these catastrophic medical events and the potential negative impact of lasered claims, managing the plan impact of one high-cost specialty drug is critical.
Cost-containment is achieved by integration and cooperation with the plan and pharmacy benefit manager to maximize prescription fulfillment through non-traditional channels.
APC connects self-funded medical plans looking to utilize the savings potential of prescription assistance programs through Rx Advocacy programs. The plan can provide brand-name drugs delivered to the member at little to no cost while strategically lowering the financial impact on the plan and the individual's stop-loss limitations.
APC works with and through Benefit Advisors and offers an up-front and complimentary Rx Diagnostic and consultation to ensure we provide the right strategies for your organization's specific needs. Please get in touch with an APC Pharmacy Benefit Consultant today if you would like more information.
When a self-funded health plan sponsor considers cost-containment strategies, it is important to factor in the current PBM's role as coordinator of the pharmacy benefit.
Cooperative PBMs work in tandem with pharmacies, plan sponsors and advocates, to establish best practices for minimizing employee disruption, lower cost solutions for employees, and maximizing prescription fulfillment through non-traditional channels. Cost-containment is achieved by integration and cooperation.
APC understands this and specializes in connecting self-funded plans with PBMs who will work with the plan's cost-containment strategies. Therefore, APC excludes PBMs that prioritize making money from drug sales, rather than processing claims are excluded.
PBMs that have the right priorities work with pharmacies and plan sponsors to identify and manage a list of high-cost brand medications that are eligible for savings for both the member and the plan.
Please get in touch with an APC Pharmacy Benefit Consultant today if you would like more information. We are an independent consulting firm with over 15 years of successfully connecting small self-funded health plans with a network of PBM and cost-containment solutions.
APC works with and through Benefit Advisors and offers an up-front and complimentary Rx Diagnostic and consultation to ensure APC has the right strategies for your organization's specific needs.
