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April 29, 2021

Remember what it was like planning a trip before the internet? You’d call hotels and airlines to check availability and compare costs, with limited information on what options existed and no real way to truly compare costs, let alone access reviews from other travelers.

Shopping for medications can sometimes feel like planning a trip pre-internet: Are you truly getting the right drug for your condition? Is there anything out there that’s more effective? And more affordable?

Thankfully, there’s a series of programs and tools that work to ensure our members are getting the safest and most effective drug for their needs at the right price. It’s called Utilization Management (UM), and it includes medication pre-authorization polices, step therapy, quantity limits, benefit tiering and formulary—the last of which was previously explored here and here.

Utilization Management takes three factors into account to guide you to the best medications for your needs:

• Quality
• Safety

• Value

In 2020, Regence received over 68,000 medication pre-authorization requests in our commercial line of business, resulting in cost savings of $19.59 per member per month to our employer groups.

Our Utilization Management team of clinical pharmacists and medical providers consider all available clinical evidence, including published national treatment guidelines and whether alternative treatments may be available, when determining PA criteria. We also factor in another critical question: What are the potential negative health outcomes from these programs?

For example, we evaluated the impact of putting PA criteria on a group of high-cost antipsychotics and antidepressants. The unexpected results of these actions were that, rather than embrace alternative treatments, members started forgoing all treatment. As a result, we removed the PA criteria.

Other examples in which we ultimately determined not to apply PA criteria include acute anti-infectives, transplant-related medications, and drugs for the treatment of HIV. In short, we’re always looking at the real-world impact of these programs on our members and making adjustments when necessary to ensure that the health and safety of those we serve is priority number one.

Are you up to speed on the various tools your employer groups can utilize to ensure their employees are receiving the right medications at the right time for a fair price?

If not, please talk with your sales representative about the suite of Utilization Management options that are available.