After several years of success with maximizing savings for our clients, Wellfleet Rx’s utilization management techniques have once again paid off, producing substantial savings for our schools and members.
During the 2022 calendar year, our utilization management program successfully saved a total of $53.41 per member per year.1 In 2022, utilization management resulted in a total plan savings of 10%.
In this blog, we’ll dive into how utilization management works, how it positively affects schools and students, and the utilization management strategies Wellfleet uses to save schools and members money.
What is utilization management?
Utilization management may seem like a complicated phrase, but in simple terms, it’s a process insurance companies use to assess claims for medical necessity, safety, appropriateness of the selected therapy, and any cost-saving options.
For example, let’s say your doctor prescribes you an expensive, brand-name medication that could lead to high out-of-pocket costs. Before approving that medication, Wellfleet Rx would reference utilization management techniques, such as identifying first-line treatment options and clinically proven generic alternatives.
Wellfleet Rx uses three types of utilization management techniques:
- Step therapy
- Quantity limits
- Prior authorization
Each of these methods can result in lower costs to students, and they can even help limit rises in yearly premiums for schools.
Savings from step therapy
The first method for increasing cost savings is step therapy. Step therapy recognizes that there is a series of clinically appropriate medications that can be used to treat any diagnosis. Generic options are generally preferred for first-line treatment, unless there would be substantial clinical benefit otherwise.
For example, consider a student who is newly diagnosed with depression. If that patient was prescribed an atypical antidepressant medication as the treatment, step therapy guidelines might request attempting other clinically effective treatments before moving to this more expensive and severe therapy. In this way, Wellfleet Rx reviews prescriptions and identifies any medication options that should be considered first, thus ensuring patients are treated safely and in a cost-conservative manner.
In 2022, step therapy saved $5.17 per member per year for Wellfleet Rx’s schools and student members.1
Savings from quantity limits
Another method of utilization management is the use of quantity limits. Quantity limits set parameters on the quantity of medication dispensed, and they align with the FDA-approved prescribing instructions. When quantity limits are used, they can ensure patients receive the correct amount of medication while also lowering the total cost of care.
For example, consider a student who receives a 10-day prescription for antibiotics to treat an infection. Wellfleet Rx will ensure the prescription aligns with clinical guidelines regarding the length of time the patient should receive that medication.
Additionally, quantity limits have the added benefit of reducing the risk of dependence when implemented with medications like post-surgical opioids or other pain medications.
Using quantity limit strategies, in 2022 Wellfleet Rx saved our members $14.52 per member per year.1
Savings from prior authorization
The last way utilization management can save money is through the use of prior authorization. Certain medications and treatments need to be submitted to your insurance company for approval before they’re prescribed. Each insurer has different guidelines for which treatments need to go through prior authorization.
During the prior authorization process, Wellfleet Rx looks at several factors when deciding whether to approve a treatment:
- Safety and efficacy of the medication.
- Appropriateness of the medication to treat the patient’s condition.
- Cost of the medication and whether a less expensive, equally effective alternative exists.
Wellfleet Rx saw significant savings from prior authorization during 2022, totaling $33.72 per member per year.1
How do students and schools benefit from utilization management?
Now that you understand how utilization management works, what are the effects on schools and students? Because Wellfleet Rx is the only formulary designed specifically for students, we specialize in medications used by young adults, such as hormonal therapies and anti-inflammatory medications. We are experts at finding cost savings for the medications most relevant to your life as a student and ensuring that your care is as appropriate as possible.
Our student members can benefit from our utilization management in a variety of ways:
- You’ll have confidence that you are receiving the most appropriate medication.
- You’ll know that your medication dosage and quantity are optimized.
- You’ll receive cost-effective medication and avoid paying unnecessary pharmacy costs.
Utilization management also has the potential to result in cost savings for schools by lowering the overall value of claims for the year, which can help combat inflationary rises in insurance premiums.
Total savings from Wellfleet utilization management
Combining all the savings from utilization management for 2022, Wellfleet Rx saved students a total of nearly $53.41 per member over the course of the year.1
Learn more about Wellfleet Rx’s student-centered formulary
At Wellfleet, we understand students’ needs. We’re committed to providing our schools and their students with the right care at the right price to their satisfaction. That’s why our formulary contains 40+ free copay medications tailored to students’ needs. Learn more about how Wellfleet Rx can benefit you.
1 Wellfleet (2023). 9331 & 9702 CY22 Member Level Detail & Savings Final 3.2.22_WF. Retrieved April 7, 2023. Unpublished company document.
2 Lazzareschi, M. (2022, August 19). Students and schools win with Wellfleet Rx utilization management strategies. Wellfleet Student. Retrieved April 7, 2023, from https://wellfleetstudent.com/managing-medical-cost/students-and-schools-win-with-wellfleet-rx-utilization-management-strategies/.