- Programs & Services
- Cost Management
- Specialty Management
- Care Management
- Member Engagement
- Health Plan Client Engagement
Helping Mitigate the Impact of Price Outliers.
Manufacturers often take unjustified price hikes on existing drugs or introduce different formulations or dosing recommendations. These drugs with artificially inflated price tags are known as "hyperinflated." As part of our commitment to help prevent waste and unnecessary spending, and to ensure appropriate utilization of medication we target and remove hyperinflated drugs from our formularies that have readily available, clinically appropriate and more cost-effective alternatives.
A flexible approach and quarterly removals — rather than annual reviews — help ensure that clients can stay ahead of rapidly changing market trends.
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To further complement these strategies, we have weekly new-to-market (NTM) reviews assessing new drugs that are priced significantly higher than other clinically equivalent alternatives. When evaluating NTM products for inclusion on our formulary, we do not add drugs that have far higher prices than clinically appropriate alternatives in their therapeutic class.
In 2021, a total of 115 drugs were blocked initially at launch through the NTM process. During the year, 11 of those products were added to coverage, resulting in a net of 104 drugs being blocked in 2021.
Our flexible management approach allows us to focus both on the drugs and dispensing pharmacies.
Hyperinflation strategy lowers costs for clients and members
Launched in 2017 to target drugs seeing very high inflation from one year to the next, we expanded our hyperinflation strategy in 2019 to target price outliers within a therapeutic category for even better cost control.
In 2021, we helped save clients $768.1M through our hyperinflation management strategies.
We continually review and identify drugs that are seeing high price increases and those that are outliers based on price, including new market entrants, and remove such therapies from our managed formularies. In 2021, we identified and removed 35 hyperinflated drugs from our template formularies. Utilization of drugs that were price outliers in their therapeutic class dropped by 88 percent, saving clients an average of $1.91 per member per month.