One year after making plan updates, the data shows Wellfleet Rx utilization management strategies are helping students and school plans alike! Student members are receiving clinically appropriate care, while the program helped save school plans more than $4.7 million!1
How the Triple Aim and utilization management strategies improve care
Core to Wellfleet’s mission is the Triple Aim – providing the right care, at the right price to the members satisfaction. So, we’re always looking for ways to improve access to clinically appropriate treatments and reduce costs for our client schools and student members. Part of that process includes continuous analysis of the safety, efficacy and cost of our formulary medications. The analysis leads us to update our utilization management strategies on a semi-annual basis to align with the findings.
Utilization management strategies are procedures developed to help ensure student members are receiving the most appropriate medications, while helping to lower the overall cost of health care. The utilization management strategies we have in place include step therapy, quantity limits, and prior authorizations.
- Step therapy – A practice that starts members with preferred medications for their treatment (a ‘step’ drug), before non-preferred medications are covered. Preferred medications are clinically safe and effective, and are generally lower-copay generic options.
- Quantity limits – A structure that puts a limit on the quantity dispensed, to help ensure safe and appropriate dosing.
- Prior authorizations – A pre-approval process where clinical criteria need to be met and prescribers may be required to submit documentation prior to obtaining the medication. This helps promote safe and clinically appropriate medication use.
Data analysis shows appropriate dispensing and big cost savings
To identify the impacts of each strategy, an analysis was completed for claims processed from January-December, 2021 under Wellfleet Rx plans. The potential cost of denied claims for products that have a utilization management strategy was compared to the actual cost of the approved claim that was subsequently submitted (if any), either for a different product, a different quantity, or the same product after review and approval. Here is what the data showed.
Wellfleet Rx saves participating plan’s money
In total, the step utilization management strategies helped save participating schools $4,791,117 from January 1, 2021 – December 31, 2021.
Learn more about the cost saving benefits of using Wellfleet Rx.
1 Wellfleet (2022). 9331 & 9702 Member Level Detail & Savings Final_CY2021_WF. Retrieved June 20, 2022. Unpublished company document.