Some trends are better than others! Prescription drug benefits are continuously targeted for cost control and improved member satisfaction.  Here are WBC’s (wbcbaltimore.com) top trends that will impact your drug plan management for 2012:

  1. Generic Utilization. With a number of blockbuster brands losing their patent protection in 2011 and 2012, the pressure for greater generic fill rates will continue to escalate. Look for GFRs in the high 70’s to low 80’s percent. Plan designs that encourage OTCs and generics will continue to grow. More step-therapy will also be automatic inclusions.
  2. Specialty Drug Management.  Specialty continues to trend in the 20% range. Look for retail pharmacies to jump on the specialty bandwagon. Also, better coordination of the medical plan side of specialty drug utilization will be examined as better tools are developed to create measurement of total drug spend.
  3. Total Clinical Care.  Look for better coordinated care management that combines medical plan case management with pharmacy utilization. PBMs have tauted their clinical program prowess for some time.  Now’s the time to step up to the plate and deliver on the promise of Population  Health Management.
  4. Direct Contracting. Caterpillar and Delta have led the way. The stage has been set for alternative pricing benchmarks and as more plan sponsors gain insight to cost plus pricing, this trickle will turn into a gusher! Certainly the publishing of Actual Acquisition Cost by state Medicaid programs will further enhance the movement by empowering plan sponsors with details on how big the pricing spreads are in traditional deals.
  5. Right-Sized Networks. We’ve said it before, but very few plan sponsors need the 60,000 store broad network. In most cases a 18,000 to 30,000 store option fits the bill and provides enhanced discounts that are well worth consideration.
  6. Outcomes-Based Contracting. Ah, the good old days of capitation! Nothing is really new in health care. Look to see contracting models built on health status and overall health outcomes as opposed to unit pricing discounts. This total health management approach is certainly consistent with the Accountable Care Organization concept, and one that will incorporate prescription drug utilization and drug therapy as part of the global budget for care.

Readers will also probably hear about predictions from some fronts about PBM consolidation as a near-future trend. Maybe so, but while some of my fellow prognosticators dwell on the importance of scale, I’ve always said that it’s not the price at which the PBM can buy, but rather, the price they are willing to pass-through to the buyer that counts.  Stay tuned!

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