Utilization management improves health
It’s no secret health care costs are trending upward. By 2025, the journal Health Affairs estimates health spending will make up almost one-fifth of the economy. In that same timeframe, prescription drug spending is projected to grow by 5.5 percent annually, faster than overall health care spending, according to Peterson-Kaiser Health System Tracker data.
Keeping this forecast in mind, Wellmark Blue Cross and Blue Shield strives to positively impact the trend without negatively impacting our members. Medically appropriate care is cost-effective care, and one way to emphasize this is through evidence-based utilization management (UM).
Wellmark bases UM programs on expert inputs from the Pharmacy & Therapeutics (P&T) Committee, recommendations from our pharmacy benefit manager and guidelines issued by state and federal agencies. These policies usually consist of a combination of:
- Step therapy: Try lower-cost prescription drug options that have been proven effective in treating a certain condition before “stepping up” to drugs that cost more.
- Quantity limits: For both safety and cost, certain drugs can only be filled to cover a certain period of time (30 days, for example).
- Prior authorization: This form, filled out by a prescriber, provides reasoning on why a particular drug is medically necessary for treatment or why a member needs to receive more than the quantity limit or should bypass the step therapy requirement. This is then evaluated by Wellmark’s Pharmacy Team.
Learn more about the different ways you can personalize your pharmacy benefits program in order to best serve your employees and your organization’s bottom line: