Utilization programs are first line of defense

July 1, 2007

While your pharmacy benefit program has no doubt been managing utilization for years with core strategies, it's important to review effectiveness often. Below are the proven strategies that payers should analyze frequently in the current market of increasing utilization.

First, make sure you're actively reviewing your programs that drive the use of generic drugs. For every for every 1% increase in generic dispensing, plan sponsors tend to save somewhere between 0.5% and 1% of their total drug spend. Most prescription drugs in the United States have a generic alternative available, including some recent blockbuster drugs such as Ambien, Allegra, Zoloft and Norvasc. To help drive generic use, consider reducing or eliminating generic copays and offering drug-class-specific information campaigns and customized explanation of benefits (EOBs) that inform beneficiaries of the savings available specifically to them by switching to a generic. In most cases, beneficiaries are glad to be informed about the savings they can realize on the drugs they're taking.

Pharmacy plans also should promote over-the-counter (OTC) drug opportunities whenever possible. In the past few years, OTC availability for former prescription-only drugs has risen significantly. Some strategies to consider include:

Keep your step therapy programs current so that beneficiaries are encouraged to use first-line therapy before using the higher-cost drug. Usually, the first-line therapy works and both the beneficiary and the pharmacy plan save money. It is important to conduct a clinical review of medications that could be added to your program at least once a year. Employer savings yield up to $3 PMPM from effective step therapy programs.

Pharmacy plans must effectively communicate with beneficiaries. Educating beneficiaries makes them cost-conscious consumers, which benefits both them and your pharmacy plan. The primary focus of member communications should be to inform and align member health decisions with plan objectives, so regular contact is helpful. In addition to print mediums, successful communication campaigns can include user-friendly Web-enabled education, CDs, videos, posters, signs placed at the point of service, and targeted communications for select beneficiaries following drug utilization review.

Each of these strategies promotes a win-win environment resulting in healthier outcomes, increased member satisfaction and lower costs.