Segal Company

Prescription Drug Benefits

Rapidly rising prescription drug costs are driving overall increases in the cost of health coverage. Segal can help multiemployer funds manage the cost of prescription drug coverage through a variety of services, including:

  • Performing Prescription Drug Program Analysis (PDPA) that audits the performance of the plan's pharmacy benefit manager (PBM) to assure that all contract provisions are being administered correctly and that the fund is receiving the maximum financial benefit from the guaranteed pricing terms
  • Evaluating and negotiating annual renewals
  • Reviewing utilization and cost data to discover ways that the plan can more effectively provide prescription drug coverage by making plan design changes
  • Providing input and advice regarding changes to the prescription program proposed by the PBM, including addition of programs, changes to the formulary, or restrictions/expansions in the network
  • Reviewing the contract to evaluate whether the terms are competitive
  • Managing specialty pharmacy costs through utilization and cost reviews, data analysis, formulary management through tiered cost sharing, clinical management, monitoring high-risk participants and step therapies
  • Reviewing prescription copays and/or coinsurance and targeting copays to encourage individual health management
  • Evaluating generic prescription utilization, generic dispensing rates and generic discounts in the current contract, and improving generic dispensing rates through aggressive plan redesign and pricing improvements
  • Implementing a tiered plan design using copays or coinsurance
  • Reviewing Average Wholesale Pricing (AWP) costs by checking the fund's contractual language on AWP reimbursement and renegotiating to address revised drug pricing
  • Evaluating carve-out if a prescription drug benefit is carved in
  • Analyzing clinical programs to determine the impact and potential advantage for both your fund and covered participants