Prescription drug spend represented 13.7% of national health expenditures in 2018, totaling $500 billion, and is expected to grow to $863 billion by 2028.[1] Formularies remain a staple in trying to manage these costs; however, payers often worry about the impact on members.
Elixir recently completed its year-over-year formulary updates to keep up with the ever-changing pharmaceutical marketplace and our Select formulary will have 124 unique brand-name exclusions that span over 38 drug classes, all with generic or lower cost preferred brand alternatives. While less than 1% of members will be impacted by formulary changes in the new year, it is our responsibility to assist members in understanding these changes and help each individual find the most appropriate alternative medication so that all members can move one step closer to achieving whole health for life.
At Elixir, our Health Solutions team looks at formulary strategy and drug management with an emphasized focus on whole-member health, ensuring members have access to appropriate drug therapies to treat any condition. We conduct the following steps well before the January 1 implementation of formulary changes to ensure each member has sufficient time to have appropriate discussions with their physician(s) regarding their personalized disease management plan:
Member Disruption Analysis – We conduct a thorough analysis to determine which members will have some type of disruption due to a formulary or drug management program change. These members are then highly managed to ensure each person has a clear path of action. This allows members to receive one comprehensive message that includes all changes and helps avoid any confusion.
Custom Member-Level Alerts – Custom messaging is developed for identified impacted members and is programed into our system so that our Customer Care team has this information readily available. Should a member call in, even if it’s prior to January 1, Elixir’s customer care representatives can seamlessly assist that member in understanding what the change means specifically to them, what action needs to be taken and how Elixir can help the member in achieving their treatment goals.
Prepared Prior Authorization Process - Elixir’s Prior Authorization (PA) team is also equipped to address any prior authorization request prior to the first of the year. Should a doctor’s office call in a PA, the team is able to discuss the upcoming changes with the doctor and assist with adjusting the prescription to meet any changes.
Automated Reminders - To ensure we have covered all bases, automated calls are delivered to impacted members reminding them of upcoming changes. During the call, they can choose to transfer to a Customer Care team member to discuss the changes, ensuring a smooth transition into the new year.
Grandfathering Difficult to Treat Conditions - We understand that each member has their own path to wellness and that current drug therapies are important to consider when making formulary changes. Our Clinical team—through carefully crafted clinical criteria—identifies disease conditions where changing therapy could put a member at risk, and ensures these members continue on their current therapy without interruption.
At Elixir, our focus is not just on lowest net cost for our clients, but more importantly, on helping members achieve whole health for life.
[1] Conti, R.M., Ph.D.; Turner, A. MA; Hughes-Cromwick, P. MA (2021). Projections of U.S. Prescription Drug Spending and Key Policy Implications. JAMA Health Forum. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2776040.