Pharmacy benefits are complex because prescription medications are complex: formularies, step therapy, prior authorizations, specialty medications, manufacturer’s assistance programs, and much more. Clinical services programs help employers better understand what they’re paying for and put some cost controls in place. But it’s not just about saving money; it’s also about ensuring employees have access to effective, proven medications to meet their needs.

There are three key factors involved when it comes to the science behind prescription benefit plan design.

Ensure alignment with national treatment guidelines

There are many organizations that contribute to determining national treatment guidelines, including government agencies like the Federal Drug Administration, healthcare coverage organizations, and medical research organizations. The MaxCare Clinical Services team understands the national treatment guidelines and uses them to make recommendations for prescription benefit plan design.

Review published clinical evidence

Even after a drug has been on the market for years, there can still be clinical studies happening to evaluate that drug’s effectiveness in specific scenarios or for use with a different medical condition. The longer a drug has been on the market, the more clinical evidence available. That often translates to knowing the drug works well compared to a newer alternative that hasn’t been fully proven yet.

When evaluating prescription costs and what’s covered or not covered, we review the clinical evidence as part of our recommendations. Newer drugs typically cost more, but sometimes they’re the best treatment based on clinical evidence. Other times, generics are well-proven and should be the first step in treatment.

Adhere to nationally accepted standards of care

The full scope of clinical evidence comes together in nationally accepted standards of care, which are another key part of determining prescription benefits. While there are some off-label uses for certain medications, we focus on the accepted standards of care that doctors and pharmacists also reference when treating their patients.

The good news is that self-insured employers don’t have to understand all of these elements to create an effective prescription benefits plan. They can rely on the right partner to make science-based recommendations and walk them through the plan design process. If you’re looking for a PBM partner, contact MaxCare today for more information about our approach.