Well-managed drug benefit plans include a variety of drug
inclusions, exclusions, and utilization management tools to
manage drug mix. A significant majority of employers
exclude coverage of experimental and investigational drugs,
hair growth treatment, over-the-counter (OTC) drugs, and
weight loss/gain products as shown in Table 47. Most
employers are covering diabetes supplies and sleep disorder
drugs. Employers use a range of approaches to manage drug
classes, including prior authorization and days supply limits
as shown in Table 48.
Employers are using a broad range of utilization management
tools in their plan designs for all diseases and conditions.
The most popular tools are refill too soon (82.4%), quantity
limits (81.4%), and prior authorization (79.4%). This mirrors
the usage of tools by 2007 employers.
The use of each tool varies for five highly prevalent diseases
that are commonly treated with drug therapies. More
employers are using disease management in 2008 than last
year to manage diabetes than asthma, high blood pressure,
and high cholesterol. The refill too soon supply limit and
retrospective drug utilization review are used most frequently
to manage drugs used to treat depression.
Utilization Management Tools
Employers and their pharmacy benefit managers employ a
variety of tools to manage drug use. These tools, listed in Table 49, and arrayed in Figure 6, range from interpersonal interventions like academic
detailing of prescribers or face-to-face pharmacist consults to
claim system edits like quantity limits and dose optimization.
Claim system edits, such as refill too soon or quantity limit edits, while often transparent to employers and members,
are highly effective in directing the proper use of prescription
drugs. Figures 6 through 11 illustrate the mix of tools used
for all diseases and the chronic conditions addressed in the