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How to Control Spend on the Highest Cost Conditions

October 23, 2017

Value Drug Program.pngThe U.S. spends more on healthcare than any other country. Nearly half of all Americans have at least one chronic condition and one in three have multiple chronic conditions[i] that they rely on prescription medication to manage. As we’re painfully aware, prescription drug spend has increased dramatically over recent years, and is expected to continue to excel at a rate of 6.4% annually.[ii]

However, with a closer look at annual drug spend, we see that the majority of healthcare costs come from just a few therapeutic classes used to treat complex conditions, including high cholesterol, diabetes, HIV, Hepatitis C, and inflammatory diseases such as arthritis and Crohn’s disease. Year after year, the costs of these conditions continue to increase, and payers struggle to balance clinical effectiveness and economic impact.

The Consequences of Complex Conditions

High Prevalence, Low Cost - In the case of conditions such as diabetes or high cholesterol, the individual drug costs are reasonable, but the prevalence of the condition within the member population is so high that plan costs for these conditions are significant. In 2015, more than 30 million Americans had diabetes, and they account for more than 1 in 5 healthcare dollars in the U.S. (American Diabetes Association). A similar number of Americans have a total cholesterol level greater than 240 mg/dL, a key risk factor in cardiovascular disease and coronary heart disease—the leading cause of death in the U.S. (Centers for Disease Control).

Low Prevalence, High Cost - Some conditions aren't as prevalent as diabetes or high cholesterol, but are extremely expensive to treat. HIV and Hepatitis C are complex in nature and require expensive specialty medications to manage these diseases. About 3.2 million people have hepatitis C, and new medications now cure more than 90% of patients. The problem is that the course of treatment can cost as much as $100,000.[iii] The number of those living with HIV is an even smaller populationabout 1 million Americans—and they spend as much as $5,000 per month for treatment, or approximately $500,000 to treat over a lifetime.[iv]

Low Adherence, High Healthcare Costs - As healthcare costs have risen, more and more plans are shifting cost-sharing responsibility to the member. With higher premiums, copays, and deductibles, members are tempted to forgo expensive treatment. The more complex the therapies, the fewer who follow the treatment regimen. On average, nearly half of all patients are not adherent to their prescription therapies, and affordability is a major driver in adherence. Non-adherence might have short-term savings, but long-term effects have financial, as well as physical consequences. This effects overall health outcomes and ultimately plan costs.

Multi-Prong Approach Helps Control Spend and Care

While there is no one solution that can address all these issues, EnvisionRx recently launched the Value Drug program to provide payers with better control of all facets of pharmacy care, from utilization to clinical support, for five high-cost conditions: high cholesterol, diabetes, HIV, Hepatitis C, and inflammatory diseases such as arthritis and Crohn’s disease. The Value Drug program offers guaranteed savings on drug costs.

The program brings together several of our offerings to deliver optimal pharmacy care. This maximizes oversight while improving efficiencies, allowing for guaranteed per prescription savings when the following programs from our EnvisionCare pharmacy model are utilized:

Select Formulary: Among the lowest in the industry, our Select Formulary has only about 100 exclusions, all with therapeutic alternatives, and delivers as much as 12% plan savings.

EnvisionSpecialty: Utilize our specialty pharmacy for tighter integration and control of specialized care. Help your members stay adherent to their specialty medications while keeping your plan expenses down with our managed copay program.

Utilization Management: EnvisionRx clinicians oversee all step therapy, necessary exclusion edits and prior authorization categorical enrollments to coordinate care.

Although optional, adding in these EnvisionRx programs with the above required ones will result in even more savings:

Rx90: At no additional cost to the plan, patients taking maintenance medications can save more on 90-day fills through the largest retail pharmacy network in the country and mail order, improving cost and care.

EnvisionCompounding: Members receive affordable, high-quality compounded medications in the best form possible for their personal needs (i.e., oral, suspension, ointment cream, etc.).

Envision Personal Savings: Discount program that provides as much as 65% savings on non-covered lifestyle medications, such as smoking cessation, weight loss and acne medications at no additional plan costs.

Fraud, Waste & Abuse: Identifies and investigates high-risk claims and pharmacies, as well as recovers funds.

When utilizing these programs in unison, savings come from a combination of discount enhancements, net rebate value, Select Formulary implementation, shared operational functions and distinct utilization management edits. The combined power of these programs provides an approach that supports the lifecycle of pharmacy care. Members receive care tailored to their specific condition, and plan sponsors receive guaranteed savings, protection against future cost increases, and optimal care for the members who need it most.

[i] Pwc, 2016. Medical Cost Trend: Behind the Numbers 2016. PwC Health Research Institute.
[ii] Pembroke Consulting analysis of National Health Expenditure Accounts, Office of the Actuary in the Centers for Medicare & Medicaid Services, July 2015.
[iii] Hiltzik, M. (2016, January 15). Is that $100,000 hepatitis treatment worth the price? Yes, but can society afford it? Los Angeles Times. Retrieved from
[iv] Krucik, G. 2014. The Cost of treating HIV: One Man’s Monthly Medical Bill. Healthline. Retrieved from


Get our solution overview to learn how to get guaranteed savings on your highest cost therapeutic classes:

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