Benefit design addresses barriers to compliance

A new pharmacy benefit design uses evidence-based medicine to target only those combinations of diagnoses and drug therapies that have been medically proven to improve health status while lowering overall health care costs. If a drug does not do both, it typically would not be eligible for preferred status.

The new design, called Dx-Rx Pairing, helps patients to follow treatment plans by addressing financial, clinical, and personal barriers to compliance. It was created by Mercer, the large consulting company.

The plan design improves compliance by minimizing financial barriers by reducing or eliminating member cost sharing for designated diagnosis/drug pairs. In addition, members whose utilization patterns indicate reduced or minimal compliance are contacted to encourage them to adhere to the preferred therapy. The plan also promotes proactive communication to prescribing physicians.

Clinical evidence shows that linking a specific diagnosis with a specific regimen of prescribed drugs results in an improvement that avoids or reduces other medical costs.

It is expected that a future version of Dx-Rx will incorporate the use of genomic testing data to maximize the effectiveness of the program and of outcomes. While the use of genomic testing is not widespread, “it is highly likely it will become more prevalent, and the pharmacy area is one of the areas where its application will be most evident,” says David Dross, national leader of Mercer’s managed pharmacy consulting arm.

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