Prioritizing pharmacy care costs in today’s economy

Integrating pharmacy and medical benefits

Less-than-optimal treatment decisions are more likely when a patient does not have integrated medical and pharmacy benefits. Vesledahl offers an example involving 2 different HIV prevention medications, each offering the same protection from HIV:

1. $20,000 per year shot a health care provider administers every other month in the office
2. $2,000 per year generic daily pill picked up at the pharmacy

Someone with separate medical and pharmacy benefit carriers may end up receiving the $20,000 shot, because their carrier and pharmacy benefit manager (PBM) are not synced up on how to manage treatments that have options under both benefits.

“If you buy your medical and pharmacy benefits together, you are more likely to end up with a better cost outcome than if you didn’t otherwise,” Vesledahl says. “If you don’t manage holistically across your benefits, you risk higher costs.”

Value-vetting is at the core of integrated benefits. Any specialty drug that comes to market is screened to ensure that it’s safe, effective and delivers tangible value in line with the price charged by its manufacturer.

“Every drug first goes through a rigorous clinical review process led by our pharmacy and therapeutics committee,” Maddux says. “After clinical review, we also ask, ‘is there a less expensive drug available for treating the same condition with similar outcomes?’ Those are the kind of cost benefits we weigh.”

Collaborating across the health system

As the variety and complexity of possible treatments grow, the potential for collaboration across the health system to reduce costs and expand access grows. For instance, carriers are working to embed patient and prescription cost information into providers’ workflows, so they are able to make more informed decisions for their patients at the point of care.

The Cancer Guidance Program (CGP) is an evidence-based treatment management and analytics service used by UnitedHealthcare to help ensure quality care and reduce costs.⁵ How it works: CGP directs oncologists to prescribe the highest-quality, most cost-efficient treatment regimen option, while also helping them quickly obtain authorizations.

“The Cancer Guidance Program improves the physician experience because it’s an easier path for physicians to get approvals for the entire cancer regimen, but it also improves the member experience because someone could potentially start the therapies earlier,” Maddux says.

Another example is UnitedHealthcare PreCheck MyScript® in which prescribers get prompted when there is a lower-cost drug alternative, saving employers an average of $285 per switch and employees an average of $111 per fill when a lower-cost alternative is selected.⁷

Optum Rx, the pharmacy care services company within Optum — an affiliate company of UnitedHealthcare — introduced a new tool this year that takes it a step further, empowering employees themselves to compare prices for traditional generic drugs based on their insurance coverage. These collaborations are becoming increasingly common and are necessary to change the trajectory of pharmacy care costs.

Launching groundbreaking initiatives

If people can’t easily afford the medications they need, they’re less likely to take them, which contributes to poor health outcomes.⁸

As part of its commitment to affordability, access, equity and innovation, UnitedHealthcare was the first in the industry to eliminate all out-of-pocket costs for 5 vital medications for eligible members: insulin to treat diabetes, epinephrine to treat allergic reactions, glucagon to treat hypoglycemia, naloxone to treat opioid overdoses and albuterol to treat acute asthma attacks.⁹

“These are life-saving drugs,” says Kelley Nolan-Maccione, chief product officer within UnitedHealthcare Employer & Individual. “Without these medications, the outcome of an event can be fatal. You don’t want to be in a situation where you are rationing them or taking a chance, because it truly can come down to life or death.” She knows from personal experience how vital those drugs are: Both she and her son have severe allergies, which have necessitated the use of epinephrine to prevent acute anaphylaxis.

Some of the emergency-use drugs covered by the new $0 out-of-pocket policy — which applies to about 8.3M members — might otherwise cost hundreds of dollars, Nolan-Maccione notes.¹⁰  “Parents shouldn’t have to choose between keeping a medication at school or at home due to cost barriers,” she says.

Prescription Drug Lists (PDL) and utilization management programs, including prior authorizations, are also helping manage the costs of some of these drugs. UnitedHealthcare PDLs, for instance, are built to incentivize employees to use covered, clinically appropriate and cost-effective medications.

Waiting for a prior authorization to get approved can be frustrating for employees. So, for certain drugs, the company has streamlined the process, such as automatically approving or removing prior authorizations altogether for certain drugs based on an employee’s pharmacy and medical claims data and diagnosis information.

The rise in pharmacy care costs on top of today’s economy will continue to challenge the entire health system to collaborate and innovate in ways they haven’t before to achieve better health outcomes, a simpler experience and lower costs.

Contact your broker, consultant or UnitedHealthcare representative to learn more.