This article is intended for Wellmark's self-funded large groups.
As an employer who provides health benefits to your workforce, the rising cost of pharmacy drugs might be one of your top concerns. Of the total benefits cost — the combined cost of medical and pharmacy benefits — pharmacy now accounts for 20–25 percent of the total spend, according to data from Wellmark's large group market segment.
Nationally, more money is spent on prescription drugs than ever before and continues to rise. In fact, drug spending is projected External Site to reach $380–400 billion in 2025, up from $359 billion in 2020, with specialty medications accounting for 53 percent of dollars spent.
What's more is the cost of name brand prescriptions is outpacing other health care services and causing patients to miss out on needed drug therapies due to excessive out-of-pocket costs and increasing premiums1.
With things heating up in the world of pharmacy, you might be thinking about how you can control costs and provide the best options for your employees.
[WEBINAR] Hear it from Wellmark's pharmacy expert
We know employers are looking for a comprehensive pharmacy management strategy that lowers costs, improves clinical outcomes and provides better member experiences. In this free webinar, Wellmark pharmacy expert, Shanda Harclerode, explains the key components of an integrated pharmacy benefit that meet those objectives.
Carve-in vs carve-out pharmacy
When employers are strategizing a benefits program, there are two models to consider: carving-in or carving-out pharmacy from medical benefits.
Carve-out pharmacy model — When an employer carves out their pharmacy benefits, it means they are contracted with a separate company from the medical benefit that administers their pharmacy program.
Carve-in pharmacy model — When an employer carves in, it means they are working with a health plan to administer both medical and pharmacy benefits.
A carve-in pharmacy model is an integrated approach, in which pharmacy benefits are part of an overall health care benefits program. In this arrangement, the medical benefits administrator will work with a pharmacy benefits manager (PBM) to process pharmacy claims and administer the pharmacy program.
The Wellmark Blue Cross and Blue Shield Pharmacy Program handles the back-end negotiations, compliance, pharmacy management strategy and leverages the scale of a top-tier PBM so your organization can focus on what matters to you — your employees and their health.
Benefits of integrated pharmacy benefits
We take a combined approach to help you meet your health care goals that leads to:
Addresses needs of specialty drug affordability and experience
With a significant number of drugs coming out soon under the medical benefit, it’s important to have the flexibility to attain coverage for specialty drugs through either the medical or pharmacy benefit, giving you the ability to evaluate differing rates between the channels. Additionally, because of the great number of specialty drugs anticipated under the medical benefit, it’s important to have a partner that can leverage the relationship with provider networks to negotiate deeper discounts for you.
Simplified plan administration
Managing multiple vendors can be time-consuming and complex. Integrated pharmacy benefits eases the administrative burden by coordinating policies, providing comprehensive reporting and consolidating billing and employee eligibility.
Lower cost of care
Research shows that businesses benefit from integrated medical and pharmacy benefits. According to a study by the The American Journal of Managed Care, total medical spending is lower External Site among businesses with integrated pharmacy and medical benefits. The savings were observed over a three-year timeframe, with the carve-in groups experiencing lower total costs and slower growth by the end of the study period.
Cost savings were found across all member populations, but especially for members with chronic illnesses in which the medical spending was even slower. This is likely due to clinical teams having increased visibility into comorbidities and high-risk prescriptions among members and being able to follow up when those members aren't adhering to their treatment plans or when lower-cost options are available.
Improved health outcomes
When pharmacy is integrated with medical benefits, coordinated claims data can identify and close gaps in care so your employees receive the best care possible. In a Cambia Health solutions study External Site, the coordinated care approach resulted in lower medical costs, fewer hospitalizations and fewer emergency visits over a one-year period.
Additionally, among chronic conditions, the study found significantly lower hospitalization and emergency events for participants dealing with asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes and depression.
A seamless member experience
There's already so much fragmentation in the health care system today. Often, members don't know which plan to call with questions or inquiries and can feel unsure navigating any part of the health care system, in general. An integrated medical and pharmacy plan solves for many of these issues by providing your employees with greater consistency and security through:
- Access to medical and pharmacy benefits with one member ID card.
- A single point of contact for viewing benefits and speaking with customer service.
We discussed the impact on members with Shanda Harclerode, team leader for Wellmark clinical pharmacy operations, and she shared a story about a member who could have benefited from pharmacy integration.
"We had a case where a member who did not have integrated benefits was hospitalized. The health care provider wanted the member to initiate a new therapy upon discharge, but the member ended up staying hospitalized for several additional days as the provider struggled with confusion around the drug coverage and authorization through the outside pharmacy benefits manager (PBM). The result was a significant and unnecessary hospitalization cost for the group," Harclerode said.
In this instance, the member could have had a better experience with combined pharmacy and medical benefits.
We are focused on helping you achieve results
Save money, time and effort by combining your Wellmark medical benefits with our innovative pharmacy program. If you're a self-funded group, download the Understand the pharmacy benefits Secure Site flyer (P-2118989) from the Marketing Toolkit to see how you can benefit from Wellmark's Pharmacy Program.
Email us at email@example.com Send Email so we can connect you with an authorized Wellmark representative to discuss pharmacy integration for your business.
1 Rome BN, Egilman AC, Kesselheim AS. Trends in Prescription Drug Launch Prices, 2008-2021. JAMA. 2022;327(21):2145–2147. doi:10.1001/jama.2022.5542