How to Make Prescription Drug Costs an Easier Pill to Swallow

Prescription drug spending continues to rise every year in the United States.1 The rise is being driven by an aging population, aggressive marketing to physicians, direct-to-consumer advertising and an increase in specialty drug usage. What used to be a small portion of benefit plan spending has crept up and now cannot be ignored. 
Specialty drugs, which often offer advancements in patient care, also raise concerns of affordability. A recent survey found that 85% of health plans consider high cost a determining factor in identifying specialty drugs.2 Medicare’s definition of specialty drugs is also based on price: Pharmaceuticals costing $600 or more per month are considered specialty.3

The good news is that of all the factors contributing to rising prescription drug spending, specialty drugs are the most controllable and Prairie States has a number of strategies to reign in costs without sacrificing quality care. Our guiding principle is the right patient receiving the right medication at the correct dosage and frequency, all at the right cost.

Partner with progressive PBMs:  We look for PBMs who are capable of providing outstanding service to you, your members and your broker. We want PBMs that can work with all of us to tailor a plan design that best suits your needs. And we want proven performance. We only work with PBMs who have a proven track record of reducing costs, improving care and controlling trend, like we do.

Partner with Excelsior Solutions:  For expert pharmacy benefit management, including audit of a benefit plan’s history to examine patterns of utilization and opportunities to recover funds, we turn to Excelsior. Their service also includes formulary management and specialty drug management medication adherence.

Maintain Access:  When we partner with a PBM, we establish a contract that gives us full audit rights to the PBMs’ network pharmacy contracts, claims data, manufacturer rebate and administrative fee contracts, mail service purchasing invoices, clinical coverage criteria, and formulary decision-making records.

We also review reporting packages from potential PBMs to ensure there’s a level of detail and practicality of the information for monitoring and addressing utilization patterns. Only when we have access to critical data can we make informed and proactive plan changes that improve health outcomes and keep costs under control.

Monitor and Intervene:  In the United States, some 3.8 billion prescriptions are written every year4, yet over 50% of them are taken incorrectly or not at all.5 It’s estimated that poor compliance costs the US healthcare systems $290 billion each year.6

Adherence is a significant element of cost containment, especially when specialty drugs are involved. We look for PBMs that provide access to nurses and pharmacists to discuss all aspects of prescription drugs with members, from filling the prescription to unboxing to education about possible side effects to adherence to maintenance regimens.

Prairie States then complements the services of the PBM and Excelsior with our own Utilization Management, Condition Management and Case Management services. Ensuring members are taking the right medication at the right time for the right reason, and getting the desired result, is critical. Our staff is especially diligent with members during the first six months on a new medication, when the risk for nonadherence is at its highest.

The overall cost of prescription drugs, largely influenced by specialty drugs, account for a larger and larger portion of plan spending. However, with access to data, strong partners and Prairie States’ intervention with members, it’s possible to keep costs under control. Count on us to work with you, plan members and your broker to make prescription drug costs an easier pill to swallow.

1. Express Scripts, “2014 Drug Trend Report” (2015),
2. EDM Serono, EDM Serono Specialty Digest, 10th Edition: Managed Care Strategies for Specialty Pharmaceuticals (2014),
3. Centers for Medicare & Medicaid Services, Announcement of Calendar Year (CY) 2016 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter (2015), MedicareAdvtgSpecRateStats/Downloads/Announcement2016.pdf.
4. Cutler DM, Everett W. Thinking outside the pillbox – medication adherence as a priority for health care reform. N Engl J Med. 2010,362:1553-1555.
5. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487-489.
6. 2010 benchmarks in improving medication adherence. Health Intelligence Network. 2010. Accessed January 4, 2014.

Prairie States Enterprises, Inc. is a third-party health benefits plan administrator that brings industry expertise and a clinical focus to self-insured companies. Our in-house claims administration, health management services, wellness programs, plan analysis and predictive modeling tools result in remarkable and unprecedented cost control for employers. We also provide the most compassionate and personalized level of service for plan members.
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