Exclude at Launch
With innovation declining, more drug manufacturers will continue to produce brand medications that lack clinical value. Often 'new' medications are not actually new only a slight alteration of an existing medication. The Exclude at Launch Program enables us to immediately exclude a high-cost medication from coverage upon its market launch. This helps eliminate unnecessary costs for you and minimize disruption for your employees by removing coverage when the medication hits the market.
In situations where medications offer no additional value over other options in their class, exclusions make sense. However, we understand exclusions can be disruptive for your members so we only make the decision to exclude a drug when it meets our criteria:
- Many other affordable and clinically similar medications are available for the same condition.
- Excluding the medication yields significant cost savings for customers.
- We can leverage the exclusion to lower the costs of the medications in therapeutic class.
As a medication is approaching the end of its patent life, it is not uncommon for the manufacturer to introduce "enhanced" products that don't always offer new clinical value, but can increase cost and gain a new patent from the FDA. One recent trend to support this would be combination packages where individual products are packaged together but the cost can increase significantly. For example:
High Cost Generics
Generic drugs can sometimes cost more than brand name drugs. Right after the patent expires for a brand name drug, the manufacturer who gets to market first with a generic has about 6 months of no competition this is called the 'exclusivity period'.
Some manufacturers set a premium price during this time to take advantage of dispensing practices that automatically favor generics. Instead of automatically placing generic drugs into Tier 1, we review and monitor them based on overall health care value and place them into the appropriate tier so that the highest value medications are the lowest cost options.
Select Designated Pharmacy
Members can save money on some high-cost medications by moving to mail order delivery, moving to a lower-tier drug... or both. The Select Designated Pharmacy program targets a few high-cost drugs and provides several cost-saving alternatives. Learn how the program works.