The advantages of integrated medical and pharmacy benefits
Better health outcomes, lower costs and simpler experiences are possible when medical and pharmacy benefits are managed together.
Given the widespread concerns about drug affordability, it’s no surprise that employers, brokers and consultants are seeking strategies to help manage pharmacy costs.
And while there are a variety of approaches to consider, one that stands out is managing medical and pharmacy benefits under a single carrier, which can support savings averaging up to $516 per member per year (PMPY).1
This is partly because prescription drug spend spans both pharmacy and medical benefits. Having a holistic view of a person’s health care can help maximize savings and optimize health outcomes. This is especially true for specialty medications related to oncology, inflammatory conditions and multiple sclerosis, which drive some of the highest costs across medical and pharmacy benefits.2,3
When these benefits are provided by separate carriers — or by a standalone or carved-out pharmacy benefit manager (PBM) — the lack of coordination and real-time data sharing may result in missed savings opportunities. In contrast, when pharmacy and medical benefits are integrated, both the carrier and providers have a clearer view into a member’s health status and their whole-person health needs. This can enable faster and more informed clinical decisions that may result in:
Voted “most capable”
UnitedHealthcare was voted the most capable carrier for providing integrated benefits, according to a survey of brokers and consultants4
- Lower costs - With integrated benefits, providers and carriers can proactively guide members to lower-cost drug alternatives and care settings, when clinically appropriate. They can also determine whether a drug or treatment may be more cost-effectively covered and managed under their medical or pharmacy benefit through the cross-benefit drug management process.
- Improved health outcomes - When data and coverage information are shared across a member’s medical and pharmacy benefits, the carrier and providers gain a more complete view of the member’s whole-person health needs. As a result, they may identify and engage members more quickly and make more informed care decisions — all with the goal of achieving better health outcomes and lower costs.
- More seamless and connected experiences - Because providers have greater visibility into a member’s medical and pharmacy coverage and utilization, health care can be more seamless and coordinated. Additionally, members can access a single view of their medical and pharmacy benefits information through digital tools like the UnitedHealthcare app® and myuhc.com®.
Cross-benefit drug management: A critical component of an integrated approach
While the advantages of benefit integration tend to be well understood in the market, cross-benefit drug management can also add additional value. This includes the process of:
- Analyzing the efficacy, financial impact and administration experience of specific drugs
- Determining whether a medication should be covered under a member’s medical or pharmacy benefit
- Managing care across each benefit to help ensure members are directed to lower-cost medications and care settings when clinically appropriate, regardless of which benefit may be covering treatment
Aside from cost, the way a medication is administered often determines which benefit will cover it. For example, medications in pill form or self-injectables are typically covered by the pharmacy benefit, while infusions are usually covered by the medical benefit.
Cross-benefit drug management becomes even more impactful when applied to specialty medications. These drugs, used to treat complex or rare chronic conditions, typically account for more than 60% of an employer’s total drug spend,7 with more than half of that spend under the medical benefit.8
Consider Neulasta®, a drug used to treat low white blood cell count (neutropenia)— a common side effect of cancer treatment:
- Step 1: The UnitedHealthcare Pharmacy and Therapeutics (P&T) Committee determines that Neulasta is an effective treatment. The Prescription Drug List (PDL) Management Committee analyzes the cost and advantages of Neulasta under both the pharmacy and medical benefits.
- Step 2: Upon review, the PDL committee finds that the cost of Neulasta Onpro® is lower under the medical benefit when administered at a provider’s office, saving $1,600 per claim on average compared to pharmacy benefit coverage, according to UnitedHealthcare 2023 claims data.
- Step 3: The PDL committee considers many factors to minimize the impact on the member’s experience, regardless of cost. Market feedback reveals that members tend to appreciate that the Neulasta Onpro device can be inserted by a provider during their chemotherapy session, eliminating the need for additional appointments or self-administration of the drug, which may be daunting for some patients.
Without this thorough cross-benefit drug management approach, the employee and their employer may have had to pay more, and the employee may have had to self-administer the drug or schedule additional appointments, potentially taking time away from work.
While some brokers, consultants and employers may believe cost savings can be achieved without integrating their pharmacy and medical benefits, such as by excluding expensive specialty medications from their coverages and working with third-party vendors to supply these medications, these “alternative funding” approaches can expose members and employers to new levels of uncertainty. This is largely because these third-party vendors often advertise access to “free” specialty drug programs run by charities and drug manufacturers, but eligibility, coverage and funding of these programs are not guaranteed and change frequently. Consequently, employers may still end up covering these drugs, often at a higher cost.
Therefore, even if offering integrated pharmacy and medical benefits comes with a higher upfront price tag, it may ultimately prove more effective in managing health care costs and maximizing savings opportunities across these 2 benefits for both members and employers, while also delivering more coordinated care for better health outcomes.
UnitedHealthcare is more effective at managing biosimilars when compared to other carriers9
Biosimilars, which are clinically similar in composition and health outcomes to their respective FDA-approved innovator (or reference) drugs, were projected to save the U.S. health system $183B by 2025.10 Currently, they are becoming a critical component of employer benefit strategies.
53% average savings
for employers generated by UnitedHealthcare biosimilar management strategies11
Employers should not only understand how a carrier manages biosimilars but also how the integration of medical and pharmacy benefits can enable additional savings opportunities.
For example, many biosimilars are available under both a member’s medical and pharmacy benefits. The UnitedHealthcare cross-benefit drug management approach works to ensure a biosimilar is the lowest-cost, most clinically appropriate option for a member and thoughtfully evaluates whether it is best covered and managed under the medical or pharmacy benefit. In fact, UnitedHealthcare biosimilar management strategies generate an average of 53% in medical benefit drug savings for employers.11
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