Drug spending in the US continues to rise and our MMA Rx Solutions team has identified through our analysis that pharmacy benefit pricing is now approaching 30% of the overall total health care cost. With this level of spending, there can be misconceptions that arise around this topic.
Our pharmacy colleagues have heard of few of the statements below that we’ve outlined for you.
- “All prior authorization processes are equally effective and operating in the best interests of the plan sponsor."
- “All prescription drug lists (PDLs) are built to achieve lower net cost for the plan sponsors.”
- “Plans who do not cover weight loss drugs do not need to worry about pharmacy spend related to GLP-1 medications for weight loss.”
Do any of these sound familiar? Have you heard them before? Let’s break them down one-by-one.
The first, “All prior authorization processes are equally effective and operating in the best interests of the plan sponsor.” Many pharmacy benefit managers (PBMs) own their own specialty pharmacy and control the prior authorization of specialty drugs. Approval of a specialty drug script drives revenue for the PBM. This can present a conflict of interest and there may be an ethical concern to have the same company that performs the prior authorizations, be the same company that makes a profit once the drug is filled. This situation can lead to incentives for the entity to approve the drug. Is your pharmacy arrangement in this situation?
The second, “All prescription drug lists (PDLs) are built to achieve lower net cost for the plan sponsors.” This particular statement refers to PDLs and their purpose. PDLs, also known as formularies, are lists of medications that are covered by a prescription drug plan. They are developed and maintained by PBMs and influence which drugs members have access to utilize. Not all PDLs are designed to prioritize lower costs for the plan and its members. Many are designed to maximize rebate payments that can drive up plan spend and PBM revenue. How is your PDL built? Do you know? Are you maximizing savings for your members and your plan?
And the third, “Plans who do not cover weight loss drugs do not need to worry about pharmacy spend related to GLP-1 medications for weight loss.” Many employers face the risk of prescription drug plan overspend because some members are using diabetic GLP-1 medications off-label for weight loss purposes. GLP-1 medications are typically prescribed to manage diabetes by helping regulate blood sugar levels. However, some individuals may use these medications for weight loss even if it is not the FDA-approved purpose of the medication. This off-label usage can lead to increased costs for employers. It is important that employers understand how effectively their utilization management criteria is addressing this risk.
In summary, with so much conversation and spending around prescription drugs, employers may look to pursue new ways to manage their pharmacy program. Marsh McLennan Agency’s Rx Solutions offers employers data-driven solutions and ongoing program management to help promote the vitality of your pharmacy contract.
We do this by using advanced analytics and pharmacy intelligence to support employers by recommending program changes, driving member engagement, and creating savings opportunities that are all aimed at improving existing pharmacy benefits.
Since the inception of our program, we are proud to share the results below:
- 15% average client savings with little to no pharmacy changes.
- More than $1 billion in total savings delivered to our MMA client base.
Interested in joining these statistics and curious on how much you could save? Visit our pharmacy plan savings estimator to discover how much you could lower your current pharmacy plan spend with little to no changes to your current contract. We are here to help. Still have questions? Reach out to one of our consultants today.
