When patients are diagnosed with
a chronic or life-threatening disease, physicians must determine if drug treatment is the best option for
their patient’s needs. Health plans utilize
several programs, including a drug benefit management program, to ensure drugs
are affordable and accessible to patients
who need them.
With a drug benefit management program, the goal is to provide appropriate,
affordable and accessible drug benefit
coverage so that positive patient outcomes are achieved, says William Valler,
associate vice president of pharmacy at
Priority Health. With such a program,
new medications are constantly reviewed
and updated. This program also works as
a type of check and balance system
between the prescribing physician, the
pharmacist and the patient to ensure that
the patient is receiving the most effective
form of treatment possible.
Smart Business spoke with Valler
about the pharmacy benefit management
program, how a drug formulary is
designed and how investing in such programs is beneficial, not only to the
patient but also to the patient’s employer.
What is a pharmacy benefit management
program?
This program combines the knowledge
of skilled medical professionals to monitor and prevent any adverse effects of
drug combinations for patients. The goal
is to operate a detailed monitoring system to provide the best care possible to
keep patients as healthy as possible. A
drug formulary — an approved list of the
most effective drugs and treatments possible — is also formed within this program. There are both positive outcomes
for the patient and the business owner
who purchases the health care with this
program.
A team of pharmacists and physicians
work to ensure that therapies are being
prescribed based on sound scientific evidence and principles. All of these methods are put in place to make sure the
patient receives optimal care.
How does pharmacy benefit management
reduce medical costs?
To reduce costs, a preferred list of formularies is established. This list ensures
that the appropriate drugs are available
to patients. The drugs on this list are
deemed the most effective and, often, the
most affordable.
There will be cases where a patient
requires a drug not on the list. This does
not mean that the patient is necessarily
denied coverage of this drug. Rather, the
patient simply has to complete an authorization process to make sure the drug is,
in fact, needed and will provide the best
treatment possible. This decision is not
made solely by an insurance processor.
With the pharmacy benefit program, medically trained professionals and pharmacists are making these evaluations.
The operator of the pharmacy benefit
management program will also work
with drug manufacturers to negotiate
costs for prescriptions and is often able
to offer drugs at a lower cost, which benefits both the employer and employee.
Why is it important for employers to invest
time and money into such programs?
For employers, the overall cost savings
is significant. If an employee is receiving
the appropriate treatment, he or she is
much more likely to recover or become
healthier. This reduces future medical
costs for employers. Appropriate treatment and medication may also increase
an employee’s quality of life and productivity. All of these are savings for an
employer.
What is the drug formulary, and how does it
work?
The drug formulary is a list of drugs
selected by a team of medical professionals who identify the most appropriate for treatment of certain ailments.
Many will likely be glad to know that the
drug formulary is developed by a pharmacy and therapeutics committee.
Medications are first reviewed to make
sure they are clinically sound. The committee must determine that the drug is
effective and that the side effects don’t
outweigh the treatment. If a drug has the
same effect for patients, then we look at
the economic side of the drug. Which
drug will be cheaper but still effective for
the patient?
In order to complete this process, the
committee does a thorough review of the
clinical and medical literature and looks
at the patient experience, the national
guidelines for related diseases, the recommended treatments for such diseases
and then the economic data. Physician
recommendations are also reviewed.
Finally, the committee determines which
drug is most appropriate for the disease
and it is added to the formulary.
WILLIAM VALLER is associate vice president of pharmacy at Priority Health. Reach him at [email protected] or
(616) 464-8918.
