Drug Management

Sep 10, 2012

Benefit plans use numerous methods to cap or manage costs. Dental plans use annual limits, lifetime maximums, deductibles and specific service codes covered and reimbursed up to the current fee guide. Under Extended Health plans, most elements are limited to the “Reasonable and Customary (R&C)” clause, per visit maximums, deductibles, annual maximums or service limits. Most of the above are smaller sized expenditures (less than $200 per occurrence).

But what about your drug benefit? Most plans today are open ended and do not have any filter or method to deal with claims that can often reach in the tens of thousands of dollars annually. Consider the drug Solaris which can cost upwards of $500,000 annually. Has your organization reviewed your drug strategy and the mechanism for members to access expensive therapies? When benefit plan sustainability is in question, an in depth review usually reveals a drug benefit which has been driving the majority of overall benefit inflation for more than a decade.

Moving away from an open ended drug design is not an easy task. Plan sponsors require confidence to execute a drug strategy. There are many moving parts to the discussion and it starts with education and engaging in many discussions on this topic. Elements such as drug patent expiry, generic drug legislation by province, expanded roles of Pharmacy, evolving rules surrounding drug manufacturer rebates, couponing to drive brand drug sales, new approval of biologic drugs and increased prescribing trends are muddying the waters considerably. The many elements have little to do with patient outcomes but more about distribution of product and market share. Add to this the almost weekly announcement from insurers of the many design developments for drug management and it can become a dizzying arena to enter. Plan sponsors need relevant and exceptional advice, yet few advisors are equipped to carry on the conversation.

The goal does not have to be a change to your program but understanding your choices . Understanding all elements of the range between status quo and a customized drug strategy can lead to an informed decision and that can provide some peace of mind in a rapidly evolving area. TRG has been developing integrated drug management strategies for many years and have been proudly driving this conversation and change within the industry. Call us.

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