Our Employee Benefit Plan Solutions
Solutions That Actually Solve Problems
Drug benefit plan costs are increasing every year with ASO Plan Sponsors themselves bearing the brunt of these increases, which can lead to a reduction in benefits coverage and/or cost shifting to members.
Most plans have seen these annual increases driven by claims for high-cost specialty drugs, sometimes costing hundreds of thousands of dollars each year, including some where their clinical value is still unknown. At the same time, there are multiple treatment options for conditions that are clinically effective, yet the significant variance in their cost is not taken into consideration by most traditional Prior Authorization processes.
Meanwhile, plan members requiring these therapies often wait two weeks or more to determine if they will be covered by their drug plan. Unfortunately, if their claim is declined, the letters they receive provide no clinical rationale, nor any direction regarding alternative options.
An optimized Prior Authorization (PA) program, where:
- Every claim for more than 150 conditions is dealt with from start to finish by an independent, licensed, Clinical Pharmacist to ensure transparency, fairness, and consistency in decision making
- Pharmacists communicate directly with the prescribing Specialist to select the most appropriate therapy and dosage for the member – the member is never caught in the middle
- Over 90% of PA claims are completed within 1 business day, and 99% are completed within 2 business days, so members dealing with challenging conditions are not left waiting for answers
- Members have direct access to their Clinical Pharmacist to discuss their case as well as access to their Medication Access Coordinator to help navigate next steps
The FACET Prior Authorization Program, where ensuring the most appropriate, and evidence-based use of complex therapies ensures members are on the right medication, at the right dose, at right time and that plan spending is appropriate and sustainable.
Transparency is key, which is why program activity is tracked and reported on every quarter – while savings generated from optimized Prior Authorization allows for reinvestment elsewhere in the benefit plan.
Plan Sponsor Controlled Pharmacies
Pharmacies commonly earn 25 – 30% of drug plan costs to distribute medications to members. For large plans, that translates into millions or tens of millions of dollars annually while members use hundreds or even thousands of different pharmacies leading to an inconsistent clinical and member experience.
Pharmacies typically earn more revenue by dispensing more expensive therapies, even if more cost-effective, equally safe and appropriate alternatives exist. The less efficient the dispensing, the more most plans and members pay. While there has been growth in clinical services that pharmacies can bill for in recent years to ensure optimal medication outcomes, the reality is that the vast majority of pharmacy revenue is derived from dispensing a product as opposed to rendering a clinical service.
A Plan Sponsor Controlled Pharmacy that removes the profit motive and misaligned business model, where:
- Avoiding unnecessary costs is more important than filling claims
- Capturing dispensing revenues as the member pharmacy allows the plan to reduce costs to members and reinvest in other areas of the benefit plan
- There is the economic incentive to invest in a dedicated Clinical Team to serve the needs of members and drive the best possible member experience
- The focus can be on helping members dealing with chronic conditions and driving optimal health to reduce workplace absence and disability – the pharmacy isn’t looking to fill antibiotic prescriptions at 10pm on a Saturday evening, it is focused on chronic conditions where its clinical experts can add the greatest value to members with more significant medication needs
Before the end of 2022, Cubic expects to be supporting plans with over $300 million in eligible drug costs annually launch and manage their own pharmacies.
How Can We Help?
We’ll discover whether or not your benefit plan is performing as it should, then work with you to do something about it.