This article is primarily intended for self-funded, large groups in Iowa and South Dakota, and was last updated in February 2020.
Let’s get straight to the point: Pharmacy costs continue to rise, and trying to merely control them is no longer a viable strategy. This year alone, the price of Humira® increased 7 percent External Site. A multidirectional approach — like offering a more managed drug list, limiting your network and combining medical and pharmacy benefits — can make a big difference in the health of your employees and your organization's bottom line.
Limit drug spend, not benefits
Prescription drugs make up almost 25 percent of Wellmark Blue Cross and Blue Shield's annual health care spending. By fully integrating medical and pharmacy benefits, you get constructive insights into care coordination while lowering medical costs (without inflating pharmacy spending as a side effect).1
Four percent lower emergency room visits, nine percent lower hospitalization events and eleven percent lower per-member per-month medical costs.
So what’s driving the costs? Within pharmacy, there are three main factors:
- The cost of the drugs themselves.
- The drug mix — whether members are using more or less costly products.
- Utilization, which includes how many people take a drug, how much drugs cost, and the quantities associated with these prescriptions.
While the first factor is largely outside our control, we can tailor the other two to make a difference on pharmacy trend and spend. We do this by tapping into the collective purchasing power and efficiencies of our national pharmacy benefits manager (PBM), while retaining local control of benefits, drug lists (known as a formulary) and clinical programs.
Local management provides your employees and their families unmatched access to pharmacies through comprehensive networks. And, we’re able to get even greater discounts by leveraging our 2 million members that we pass back directly to you.
- Network options range from broad access to cost-controlled, so there’s a choice that meets the needs of both you and your employees.
- Fiduciary responsibility and independent oversight mean we are responsible for properly and efficiently managing our book of business through sound decision-making, third-party audits, and ongoing market checks that directly benefit your organization.
- Member engagement includes easy-to-use self-service digital tools, 24/7 availability to talk to health care professionals, and advanced care nurses when needed.
Expert evaluation by our Pharmacy & Therapeutics (P&T) Committee, which consists of local doctors and pharmacists that select medicines based on safety, effectiveness, and a drug's true value, not just cost or rebate opportunities.
- Formulary decisions, including tier or level placement, helps drive usage to the safest, most effective (both performance and price) prescriptions.
- Utilization management helps ensure medically appropriate care through evidence-based recommendations and policies.
Independent channels keep your costs as low as possible. We divide pharmacy management into three cost-saving components: pharmacy benefits, specialty drug and mail order. Again, this ensures we’re securing the best deal for you and not shuffling dollars from channel to channel to tell a better story.
The difference of pharmacy integration is in the details
By managing your medical and pharmacy benefits together, you can positively impact your overall health insurance benefits — both costs and experience. We work side-by-side with you and your organization to keep your benefits cost-effective and accessible.
| Wellmark Pharmacy Program | Other pharmacy benefit managers |
|---|---|
| Pharmacy leveraged alongside medical to reduce overall health care expenses | Pharmacy managed separately, which can lead to increased costs on the medical side |
| Specialty drugs managed on both medical and pharmacy benefits for coordinated care | Specialty drugs disconnected between medical and pharmacy leading to potentially negative patient experience |
| Full disclosure of price points for greater insight and transparency | Opaque pricing can lead to confusion of true costs versus pharmacy benefit manager profit |
| Designed to promote safe, high-performing, cost-effective drugs for efficient care | Designed to chase rebates offered by drug manufacturers that can inflate total spend |
| Holistic look at total cost of care for greater understanding of your health care usage and trend | Focused on pharmacy costs only, which can inadvertently increase medical costs |
| Aligned with your needs in managing health care costs without sacrificing safety and effectiveness | Aligned with profits, lowering overall value to you and your employees. |
Let us do the heavy lifting
By combining innovation, transparency, cost management strategies, and a full range of clinical programs, we can encourage the use of lower-cost drugs without limiting access — or performance — for your employees and their families.
Enlist Wellmark to handle the back-end negotiations, compliance, pharmacy management strategy and independent PBM oversight, and your organization will be free to focus on the details that matter to you.
We know that pharmacy — and the costs associated with it — continues to be top of mind. Keep up to date on the latest insights, resources and more from our pharmacy experts. Or, email us at blueatwork@wellmark.com Send Email, and we'll connect you with an authorized Wellmark representative to learn more.
1 Source: Blue Cross Blue Shield Association and Prime Therapeutics LLC. “Economic and event outcomes of members with carve-in versus carve-out pharmacy benefits: A two-year cohort study,” 2014.
