In accessing the various pricing strategies that were discussed in John Jones’s article, as a PBM (Pharmaceutical Benefit Manager) I would most likely recommend going with the strategy of Utilization Management because there are so many ways you can allow or not allow things to be in your power. And by being able to reduce unnecessary prescriptions to be filled by employees could help save a lot of money for the employer. Another reason this could help is by allowing the access to quality drug medications by the 5 R’s which are, “The RIGHT diagnosis at the RIGHT time, and the RIGHT medication, in the RIGHT dosage over a period of time that is RIGHT for that patient.” (J. Jones) In order to make sure of better patient outcomes.
Here are a few more strategies that I would implement:
~Exclusion of specific drugs or drug classes from coverage- Some drugs that were previously excluded are now covered but placed in a coverage category with a really hefty copayment, or are covered only under prior authorizations, or as part of a type of utilization management program. In other cases drugs may be covered only for certain categories of patients such as growth hormones where there is documentation that a child has a medical syndrome causing him or her to grow too slowly, or in association with certain programs like appetite suppressants for a patient who meets with a nutritionist on a regular basis
~Exclusion of over-the-counter drugs from coverage- Cost tradeoffs can sometimes create a rationale for covering an OTC drug. If a plan covers prescription pain medications, but does not cover aspirin or ibuprofen, it’s harder for me as a PBM to recommend a substitution on a medicine that is a nonprescription medication. Let’s take aspirin for example, the total cost might be lower than the copayment on an expensive alternative like a Cox-2 inhibitor. But in cases like Claritin, the cost of the OTC drug is much higher; as a matter of fact, it may be cheaper for a person to...
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