1. Flexible plan options and programs that can be tailored to employers’ needs
When it comes to drug coverage, our pharmacy management programs effectively help contain costs while managing quality. We tailor programs to meet an employer’s specific needs, and we offer a value-based pharmacy benefit to encourage preventive care. Our multi-tier prescription drug plans are designed to keep members healthy with the best-possible clinical outcomes at the lowest net cost.
The cost of prescription drugs accounts for almost 20% of health plan spending, and 1 in 3 employers say specialty prescription medication was their highest driver of health costs in 20162,3
We tailor programs to meet employer-specific needs.
- Choose Tiers: Employers can choose how many tiers they’d like to offer to employees with flexible options like a 3-tier copayment plan that encourages use of lower-cost generic and preferred brand medications. And a 4th tier to help manage high-cost specialty drugs.
- Add Preventive Care Benefits: Our optional value-based drug benefit program supports the power of preventive care. For little-to-no copayments, high-risk employees get access to preventive medications for conditions like high blood pressure, high cholesterol, diabetes, asthma, heart attacks, and strokes.
2. Advanced member and provider engagement strategies
At Tufts Health Plan, we reach out to members and providers directly to help inform them of lower-cost drug options.
- Our outreach program targets members who are using high-cost drugs that have lower-cost alternatives, and encourages them to speak to their doctors about new options.
- We work directly with providers to promote evidence-based prescribing, review clinical guidelines, and raise flags when employees are struggling with adhering to their medication treatment plan.
- We use value-based contracting to hold providers accountable for managing the total cost of care including prescriptions. So providers are encouraged to prescribe drugs their patients prefer and can afford.
Specialty drugs represent 38% of the American public’s total pharmaceutical spending4
Special programs designed to help members save on high-cost prescriptions. We’ve got programs in place to promote the best possible care at the lowest net cost to our members.
- Tiered plans encourage the use of lower-cost generic or preferred brand medications through lower copayments.
- Of course, members can choose different medications from our formulary if they’d like to; it just may come with a higher copayment.
Advanced digital tools help members better manage prescription needs, including:
- Convenient, mobile-based refill management and refill alerts.
- Pickup of specialty drugs at retail locations.
- Access to information and support to search for drugs, understand their cost, explore lower-cost options, and share that information with their doctors.
3. Specialized teams for medication support
When members closely follow their prescription treatment plan, it improves health outcomes and decreases health care costs.5
Our specially trained Care Management team is dedicated to keeping members on track with their medication treatment plan. Care managers are paired one-to-one with members who need extra support, and together they establish a health care plan and work toward achieving it.
Our care managers incorporate data from our pharmacy benefits manager directly into their care planning discussions with members. This means they’re working with members to identify and remove barriers to medication adherence, like affordability, sensitivity to side effects, knowledge, or language barriers. They will even facilitate conversations between members and providers to identify alternative medicines that might cost less, or be more desirable to members.
With the help of our care managers, our members maximize their prescription savings, paying only for the medicine they need, when they need it.
4. Integrated Pharmacy Benefits Manager
At Tufts Health Plan, we believe a fully integrated approach to pharmacy benefits management is the best way to provide quality and fully-coordinated care. We work hand in hand with our pharmacy benefit manager (PBM), to maximize savings to members and employers.
One of the largest employers in the state saved $8 million by using our integrated pharmacy benefits manager.
Good data leads to better outcomes
Integrated pharmacy benefits management means data about prescriptions and drug adherence can be shared in real-time across our organization, so our care managers can incorporate pharmacy data into their care planning and engagement discussions with members.
Comprehensive, affordable pharmacy benefit
The integrated pharmacy benefit model has positively impacted our ability to provide members with a comprehensive and affordable pharmacy benefit while simultaneously controlling our overall pharmacy trend. Some examples of these advantages include:
- Integration of clinical, pharmacy operations, contracting, and analytic expertise under one umbrella. Effective, efficient, highly coordinated management of pharmacy benefit, formulary, and pharmacy utilization management programs.
- Management of medical and pharmacy expense by disease state.
- Management of Specialty Pharmacy costs across all places of service.
- Coordinated condition program implementation like smoking cessation, diabetes management, and weight loss.
- Aligned incentives between our pharmacy benefit manager and employer groups.
5. Active management for specialty drugs
Managing specialty drug costs is a critical part of the way we manage overall pharmacy spending. We work with our pharmacy benefits manager to secure price protections, reassess preferred drug strategies, and negotiate rebates for new drug launches.
Constant spend evaluation
We regularly evaluate spend and trend by specialty condition, including both pharmacy and medical, to help ensure we understand specialty drug use for entire populations, as well as for individual members.
Careful drug management and contracting strategies
At Tufts Health Plan, we are meticulous in our management of specialty drug use, employing strategies based on clinical efficacy and lowest net cost, with consideration given to available rebates both through the PBM and directly from manufacturers.
- Using our PBM’s negotiating leverage with manufacturers (they cover more than 75 million lives) we are able to secure significant rebate value.
- We maintain certain drugs under our medical benefit, rather than our pharmacy benefit, in order to realize savings in the form of rebates, better negotiated rates, and member cost-sharing.
- Since specialty drugs so often require specialized services such as delivery, dosing, patient support, and storage, we contract with a Specialty Pharmacy provider to dispense these medications and provide care management for specific disease states. These pharmacies specialize in providing specialty medications and are staffed with nurses, coordinators, and pharmacists to deliver support services for members.
Recent negotiations with our pharmacy benefits manager yielded savings in excess of $6 million. These savings directly offset premiums for fully insured clients.
Monitoring the drug pipeline
It’s not just our job, it’s our responsibility to understand the future of specialty drugs. New therapies are constantly being researched. At Tufts Health Plan, we make it our business to monitor the specialty drug pipeline and assess its impact on our members based on the prevalence of those conditions.