Come on in, the water’s fine

Employers report that managing drug trend is their number one priority.1 And most of us know that an exclusion formulary is one of the best ways to manage trend. In fact, 79 percent of employers use them.¹ But I was surprised to find out that most employers only use exclusion formularies for an average of five therapeutic categories.²

When asked why they don’t use exclusion formularies more, employers say their number one concern is member dissatisfaction.1

Our research shows that Prime’s exclusion formulary (NetResults) does save money and lower pharmacy trend. But more importantly, use of NetResults is not associated with an increase in the use of medical resources or costs. And adopting an exclusion formulary does not have to lead to member dissatisfaction—at least, not when you do it Prime’s way.

NetResults delivers the numbers

Since its inception in 2017, clients using the NetResults formulary have saved $10 to $14 per member per month (PMPM). Drug trend for commercial clients that adopted NetResults was 11 percentage points lower on average compared to clients not using it.

NetResults delivers extraordinary value in three ways: a differentiated framework, price to value measures, and no increase to cost of care.

NetResults has a unique and differentiated framework. We have more exclusions because we’re not just focused on brand-name drugs. Prime’s approach for NetResults is broader, based on these four category definitions:

1. Driving increased use of preferred brand-name drugs
2. Reducing extraneous costs by excluding non-essential drugs
3. Removing prescription drugs when over-the-counter (OTC) drug options are available
4. Excluding high-cost brand-name and generic drugs where lower cost alternatives are available

Category 1 focuses on brand-name drugs. That’s typical for exclusion formularies. But Prime goes further to drive down ingredient cost in Categories 2, 3, and 4.

Some manufacturers are combining inexpensive OTC medicines and charging high prices for new, single pill formulations.³
NetResults excludes those drugs.

For example, Category 3 excludes expensive drugs that are combinations of cheaper drugs. Some manufacturers are combining inexpensive OTC medicines and charging high prices for new, single pill formulations.³ The active ingredients that make up the new formulations are generic drugs that could be purchased separately, often for just pennies a pill.

Prime uses price to value measures. Since 2016, Prime has been a flagship member of the Institute for Clinical and Economic Review (ICER). Prime uses ICER and other cost-effectiveness information in the formulary decision-making process to ensure clinically effective, low net cost products are available.

NetResults does not increase total cost of care. Besides delivering significant pharmacy savings, Prime’s latest research demonstrates that NetResults does not adversely impact total cost of care. As a total drug management company, we’re not interested in simply moving costs from one benefit to another. We’re able to manage the total cost of care.

Findings from Prime’s new research

Prime’s recent study of the NetResults formulary asked the question: “Does excluding 300 drugs drive increased use of medical resources and thereby increase costs?” The answer was “No.”

The study looked at 115,000 members across four Blue plans who began on the NetResults formulary on Jan. 1, 2017, then looked back one year to Jan. 1, 2016 when they were not on an exclusion formulary. Those members were compared to the year after they started on the exclusion formulary, Dec. 31, 2018.

Researchers compared these results to a control group from the same Blue Plans of more than 750,000 who were not on the exclusion formulary during that time.

Prime found no difference in medical benefit health care resource use (i.e., hospitalizations, emergency room (ER) visits, or office visits) and no difference in medical costs among the NetResults members compared to the control group of non-NetResults members.

Prime’s research clearly demonstrates that adopting NetResults was not associated with additional medical attention for the members who were asked to switch medicines.^.4. There was:

• No increase in medical costs
• No increase in hospitalization rates
• No increase in doctor visits
• No decrease in adherence rates

NetResults implementation plan eases disruption concerns

Groups that have adopted NetResults have experienced no measured decrease to member satisfaction. Members still have safe and effective therapies available to them. Most members will find their medicines on the list. Those who do not, will find easy-to-follow steps that guide them through their options. This will help ease any disruption and encourage understanding of generic drug alternatives and preferred brand-name drugs.

Prime offers a comprehensive implementation plan before moving members to NetResults. Member communication plays a critical role. Prime works with clients to send targeted communications to each member to help explain his or her options.

The results are evidence-based

Exclusion formularies have been around for a few years. But, as always, Prime did extra homework to make sure our product achieves the desired outcomes. NetResults has been proven to drive pharmacy savings. And we have the research to show that it also delivers total cost of care results.

References

1. Pharmacy Benefit Management Institute. 2019 Trends in Specialty Drug Benefits, Plano TX. PBMI. Available from www.pbmi.com/Specialty Reports
2. Pharmacy Benefit Management Institute. 2019 Trends in Drug Benefit Design, Plano TX. PBMI. Available from www.pbmi.com/benefitdesignrpts.
3. “Drugmakers Turn Cheap Generics Into Expensive Pills,” by Denise Roland. Oct 20, 2016. Wall Street Journal Copyright ©2019 Dow Jones & Company, Inc. All Rights Reserved. Accessed at: https://www.wsj.com/articles/drugmakers-turn-cheap-generics-into-expensive-pills-1477849345
4. The drug classes specifically followed were asthma, diabetes and heart failure (betablockers utilizers). Champaloux S, Hermes M, Giguere J, Kunze A, Gleason P. Exclusion Formulary: Assessment of Medical Costs, Pharmacy Costs, and Resource Utilization Compared to a Concurrent Control Group. Academy of Managed Care Pharmacy: San Diego, CA. J Manag Care Spec Pharm 2019:25(3-a):S21. Accessed at: https://www.primetherapeutics.com/content/dam/corporate/Documents/Newsroom/Pressreleases/2019/amcp-posters/news-amcp-2019-netresults.pdf