Practical steps employers can take to manage their pharmacy benefit manager (PBM) contracts to avoid waste and control their specialty drug spend include:

Identify the number of individuals with rare conditions to determine the current cost to the plan and help track potential waste.
Evaluate current benefit plan design to determine which specialty pharmacy network strategy is in place (e.g., exclusive, open). Specialty pharmacies are often connected to the PBM and when this occurs there is a financial interest to filling prescriptions, potentially creating waste. Designating specialty pharmacies for specific disease states such as hemophilia treatment centers can reduce waste, improve patient outcomes and create savings for the patient and the plan.
Identify what utilization management strategies are in place (e.g., prior authorization, step therapy, preferred drug list). Delaying access to the most appropriate drug can impact the patient's physical and financial health both in the short term as well as in the long term.
Be aware of how patient copay assistance and copay accumulator programs may collide and result in shifting more cost to the member.
Educate members on the benefits and risks of enrolling in a high deductible health plan and highlight member cost-share responsibility when prescribed a high-cost drug.
Hold vendor partners accountable. Work with a neutral third party such as the National Hemophilia Foundation to conduct a retrospective claims audit that can be used as the baseline for driving prospective strategies and to ensure vendors are doing what is required through quarterly reporting.

In addition to the mentioned strategies, many employers find value in collaborating with other human resource and benefit executives to share best practices and learn from one another in the programs and network enabled by the non-profit Midwest Business Group on Health. The organization also makes available free resources for all employers, including toolkits.

Instant Insights /

Employer strategies to manage costs for rare diseases

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