John Ottavi, CPCU, GBA
Cottingham & Butler
The program will broadly hit on pharmacy cost containment with a focus on Specialty. Employers have not implemented many fundamental cost containment strategies including:
- Step Therapy
- Mandatory Generic
- Mandatory Maintenance Mail Order
- Prior Authorization
- Excluding Compounds – Prior Authorization on Compound medications
- Excluding manufacturers coupons – this is tough one for the PBM’s
- Medical necessity on Specialty RX –
- There are six defensive walls employers should build around Specialty to protect plans. Any specialty prescription that wants to be paid from plan resources should pass through six checkpoints:#1: Should the drug even be covered?#2: Is the drug appropriate for the member?
#3: Has the member been incentivized to use available alternatives?
#4: Has the supply of the drug been minimized?
#5: Has the cost of the drug been minimized?
#6: Have you ensured the member is actually paying their cost sharing?