As industry stakeholders take action in response to COVID-19, here’s what self-insured plan sponsors need to know



Tracy Spencer, SVP Employer Groups and Strategic Clients
April 6, 2020

Most of our inboxes have been flooded with hourly updates on COVID 19, and PSG has been reviewing and evaluating the actions of pharmacy benefit managers (PBMs), health insurers, pharmacies and other industry players in response to the pandemic. Here’s a quick summary of recent actions taken by PBMs and the key points plan sponsors need to know to ensure these actions work as intended.

 

Removal of refill-too-soon limits. Due to changing hours of access to pharmacies, as well as looming stay-at-home orders by state governments, most PBMs initially relaxed the refill limits that have traditionally been used to prevent patients from refilling a prescription too soon. By relaxing these limits, PBMs were allowing for patients to maintain adequate supplies of medication on hand should access be compromised due to COVID-19.

While the intent was positive and well-received by plan sponsors, medication stockpiling became an unintended consequence during this uncertain time. To prevent against potential drug shortages, some PBMs have already reinstated certain refill limits or placed quantity limits on medications being touted for off-label use in COVID-19 treatment, including asthma inhalers and drugs used to treat HIV, rheumatoid arthritis and lupus.

Even outside of PBM protocols, some pharmacies are implementing their own inventory management guidelines, allowing only a 10-days’ supply of some medications to guard against drug shortages.

 

Proactive 90-days’ supply of specialty meds. In response to concerns about access to specialty medications, a handful of PBMs began proactively offering a 90-day supply to patients refilling 30-day supply specialty prescriptions. There are differing opinions among plan sponsors surrounding this action.  Plan sponsors aren’t looking to restrict access to specialty medications, but some are concerned over the unbudgeted financial liability, as well as potential waste that could result from this change. For example, most specialty medications have specialized storage requirements, including refrigeration, and household refrigerators may already be stocked up to prepare for extended stay-at-home orders. Given this reality, there is a higher likelihood that specialty drug storage requirements may not be complied with – potentially contaminating the additional supply, rendering it useless and creating waste and added cost burden to both the plan and the member.

Currently, PBMs are not reporting any member access issues for specialty drugs, so we recommend that self-funded plan sponsors explore opting out of this action to appropriately manage these costly drugs and avoid potential waste.

 

Extending prior authorization expiration dates. Patients have already experienced restricted access to office visits and lab work, and we anticipate this will continue for the foreseeable future. Some PBMs have announced they will be extending the prior authorization (PA) approval date for PAs set to expire in the next 30 to 90 days. We agree that extending these approvals is an appropriate action for the near future, but plan sponsors should monitor this closely and reestablish PA protocols as soon as possible once access to care concerns are behind us.

 

Looking toward the future: Industry stakeholders are taking appropriate measures to ensure patient access to critical medications while protecting the drug supply. Health and safety have never been more important. When these unchartered waters with powerful waves begin to calm, it will be incredibly crucial to reinstate cost containment guardrails as quickly as possible. Plan sponsors could also use that time as an opportunity to reevaluate the effectiveness of the services and protocols of their pharmacy plans.



Tracy Spencer is a recognized industry leader with more than two decades of pharmacy and medical benefits experience developing and expanding relationships with C-suite and executive leadership of numerous Fortune 100 companies.