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National Alliance Releases Resource to Help Employers Better Manage Drug Costs Under Medical Benefit

Report features assessment of health plans and medical medication management strategies to assist healthcare purchasers in achieving better value

WASHINGTON – Sept. 8, 2021 – With the emergence of specialty therapeutics, the cost of prescription drugs covered under a medical plan instead of pharmacy benefit has increased substantially. To improve value of these high-cost medications for employers and other healthcare purchasers, the National Alliance of Healthcare Purchaser Coalitions released an analysis of drug management in the health plan setting with strategies to help purchasers better manage the medical side of drug benefits.

“Even though the medical side of drugs is one of the fastest growing expenses under benefit plans, it’s largely avoided scrutiny,” said Michael Thompson, National Alliance president and CEO. “Our analysis found a significant degree of variation in practices and an uneven accountability to purchasers. Employers must set united expectations and be more engaged to achieve consistent value-based care for their employees and family members.”

The eValue8™ plan performance evaluation highlights the results of what health plans are currently doing to manage drug spending under the medical benefit. The online assessment was completed by eight national and regional health plans that offered insights into the policies and procedures used to manage medical benefit drug expenditures. Responses were reported in five categories and findings include:

Achieve claims transparency

  • Only one in eight of the plans pass manufacturer rebates back to employers; 87.5% have outcomes- and/or value-based contracts with manufacturers; and 37.5% pass back to employers the outcomes-related penalties received from manufacturers
  • Specific to contract audits, no respondents offer auditors open-book access to pharmacy network contracts, payments and reconciliations, contracts, payments, and reconciliations, or pharmaceutical industry contracts, receivables, distributions and reconciliations

Minimize wasteful spending

  • Almost all plans require genetic testing to determine drug eligibility when applicable; all plans reviewed ensure that the drug dosage prescribed meets clinical criteria; and 67.5% responded that they evaluate continuation of therapy with respect to disease progression
  • Only half indicated that policies are in place that require medications be dispensed utilizing appropriate vial sizes to minimize waste

Manage value

  • The responding plans are generally working to direct treatment to the most cost-effective sites of care and three of eight are using patient incentives like lower cost-sharing arrangements to steer patients to higher-value care sites
  • Almost all are actively reviewing biosimilar policies, however biosimilar uptake in the US is relatively slow
  • 75% of responding plans offer education and outreach to patients to use a biosimilar and half reach out to encourage patients on a biologic to switch to a biosimilar; however, it is not known if this is a consistent practice across a majority of plans

Supply actionable data

  • Only half of the plans require providers submit itemized bills for a select set of medications administered in the inpatient and outpatient settings

Support patients to achieve optimal outcomes

  • Responding plans all have traditional patient outreach processes for adherence to treatment, but few offer patient-centered social support, such as patient chat rooms or trained peer support

The findings in the report, “Achieving Value: Medical Side of Drug Benefits, A Deep Dive Powered by eValue8,” along with an employer checklist is available and can provide employers and other healthcare purchasers a guide they can use in their discussion with health plans – accessed full report here.

About eValue8

eValue8™ is a resource of the National Alliance that assesses health plan performance and highlights key areas of improvement as well as areas of excellence. Performance reports allow participants to evaluate health plans on a local, regional and national level. Plans and purchasers receive objective scores enabling comparison of plans against regional and national benchmarks and a roadmap for improvement. Plans learn what they need to do to align their strategies with purchaser expectations to maximize the value of the healthcare investment and ultimately improve health and quality of care.

About National Alliance of Healthcare Purchaser Coalitions

The National Alliance of Healthcare Purchaser Coalitions (National Alliance) is the only nonprofit, purchaser-led organization with a national and regional structure dedicated to driving health and healthcare value across the country. Its members represent private and public sector, nonprofit, and Taft-Hartley organizations, and more than 45 million Americans, spending over $300 billion annually on healthcare. To learn more, visit and connect with us on Twitter and LinkedIn.

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Media Contact

Cary Conway
Telephone: 972.649.4707