By Alex Evans, PharmD, MBA
Formulary management can result in significant savings for health plans and combat rises in prescription drug prices, but effective formulary management also requires regular updates that lead to many plan members needing to switch therapies. In practice, this can result in not only frustration for the patient and their care team but also gaps in care, putting the patient at risk for adverse outcomes.
Picture this: A patient who has been on the same medication for their chronic condition for several years comes to the pharmacy for their regular refill, expecting it to be ready. This time, however, it is excluded from their plan's formulary, so not only is the medication not ready but it also cannot be filled. Without effective pharmacy solutions, the pharmacist or patient will be stuck calling or going on the plan website to find alternatives. In the meantime, the patient might leave without any medication in hand. For many chronic diseases, including heart failure, diabetes and HIV, the resulting low adherence is tied to poor outcomes and increased healthcare costs.
As a pharmacist of 12 years who has spent most of my time in community pharmacy, I have seen this first-hand countless times, especially around the beginning of the year, when formulary changes are most common. I have also seen this first-hand as an embedded pharmacist within a rheumatology clinic, where formulary changes resulted in missed doses of specialty medications, frustration for both the patient and provider and increased office visits.
Formulary optimization is critical for cost control
Still, formulary optimization is essential for payers to control costs so they can keep premiums affordable while staying financially viable. A study by the Commonwealth Fund, for example, analyzed 15 self-insured plan sponsors and found that eliminating high-cost, low-value drugs from the formulary could result in savings that represent up to 24% of their total outpatient pharmacy expenditure. Overall, they found that just eight drugs accounted for up to 21% of all potential savings.
Their findings support the importance of specialty management, too: Specialty drugs made up just 0.1% of all wasteful prescriptions in the study, but each wasteful specialty prescription would generate an average of $2,221. By comparison, each wasteful brand-name prescription would generate an average of $682, while each wasteful generic prescription would only generate $212 in savings.
This is especially concerning for payers because the specialty drug market, and its share of overall drug cost, is only projected to increase. Specialty drug substitution could even be written into law in the future: The Star Rating for Biosimilars Act, introduced in the House of Representatives in 2021, would require CMS to establish a quality measure under the five-star rating system that would measure "the level of access plans provide to covered biosimilars, including with respect to formularies, cost-sharing, and utilization management."
Outcomes helps plans implement formulary changes
Thankfully, Outcomes pharmacy solutions allow payers to implement formulary changes smoothly so they can take advantage of formulary savings while preventing gaps in care.
The first solution offered by Outcomes, Formulary Optimization, helps plans empower pharmacists and places them at the core of the implementation strategy. With Formulary Optimization, Outcomes works with payers to identify affected plan members and alerts partner pharmacists to formulary changes with a TIP in the OutcomesOne platform. Pharmacists are then able to work with the patient and provider to get a new prescription for the covered medication and provide patient counseling before they run out of medicine.
The new Outcomes offering, Specialty Trend Solutions, adds to this by providing robust support for specialty medications. Increased member and prescriber engagement is required for transitioning specialty products because members have likely gone through multiple therapies before taking the specialty product. This creates heightened sensitivity by both the prescriber and the patient when discussing a change in therapy. This solution leverages multiple modes of outreach to engage members affected by formulary change, including text and outreach from our telephonic Patient Engagement team. . This team is staffed with qualified pharmacists and pharmacy technicians who close the loop by proactively gaining buy-in from members on therapy change, providing product-specific counseling, engaging the prescriber to obtain a prescription for the new product, and working with the specialty pharmacy to ensure it is filled and delivered.