In today’s fast-paced healthcare market, your bottom line depends on how quickly your Pharmacy Benefits Manager (PBM) can react to prescription market trends. Below is a summary of a few of our Q3 and Q4, 2023 coverage decisions that should help control costs for our clients and provide better access to effective medications for their members in 2024.

Expanded coverage for Mounjaro and buy-up options for additional GLP-1 coverage

A recent study[1] noted nearly half of American adults are interested in taking a safe and effective prescription anti-obesity drug like Ozempic to lose weight. One survey[2] found that employees would rather have coverage for anti-obesity medications than other benefits like childcare. Researchers discovered that some workers are willing to leave their jobs (or stay at one they hate) and cut back on spending across the board to get their hands on these medications. In fact, 67% of respondents stated they would be “likely” or “very likely” to stay at a job they didn’t like to sustain coverage for weight loss medication.

These surveys make clear the need for a PBM to balance controlling costs with providing high-demand medications like GLP-1s.

Scripius (the Pharmacy Benefits Manager for Select Health, among other health plans and systems) is addressing that need by providing additional GLP-1 access to patients who have Type 2 Diabetes. Scripius added coverage for Mounjaro (a brand drug similar to Ozempic), after negotiating a significant price decrease with the manufacturer. The drug is covered with a preauthorization. Mounjaro’s addition to our covered drug list helps us to serve the needs of members while controlling costs.

Additionally, for patients who are overweight or obese, the addition of GLP-1 coverage to our new weight loss rider provides employer payers additional options for prescription coverage for weight management.

Saving clients an estimated $37 million in a biosimilars world

Scripius added Amjevita and Hadlima, which are FDA approved biologics that are highly similar to Humira and used to treat similar conditions. Clients often ask what is a biosimilar therapy? We make the comparison to insulin. Most of the injectable insulins that people with diabetes use are not identical to human insulin. They are a biologically similar therapy that is almost identical to the insulin that your body makes. The addition of Amjevita and Hadlima is expected to generate a total of $37 million in savings (inclusive of rebates) for our commercial health plans and employer payers in 2024.[3]

PPIs and H2 Blockers

Scripius will also save about $5 million in 2024 for commercial health plans and employer payers with our new PPI (e.g., omeprazole) and H2 Blocker (e.g., Pepcid AC, Zantac) coverage. We removed coverage for these over-the-counter medications and instead gave our members and their prescribing doctors access to several new cash pay options, including Mark Cuban Cost Plus Drugs, that distribute three and even fourth month supplies of these medications at a very low cost. This new strategy provides convenient, low-cost access to acid reflux therapies, while providing our clients with significant savings.

PBM agility saves clients money

Our Q3 and Q4 coverage changes represent the kinds of savings that are possible when a PBM is agile enough to respond to market changes. If you're looking to save money on your prescription drug offerings, contact Scripius or talk to your benefit consultant.

Note: Select Health/Scripius may refer to the drugs or pharmacies in this article by their respective trademarks, but Select Health/Scripius does not own those trademarks; the manufacturer or supplier owns the trademark. By listing drugs or pharmacies, Select Health/Scripius does not endorse or sponsor any drug, manufacturer, or supplier. These manufacturers and suppliers do not endorse or sponsor any Select Health/Scripius service or plan and are not affiliated with Select Health/Scripius.

[1] https://www.healthline.com/health-news/ozempic-coverage-important-work-perk

[2] https://www.healthline.com/health-news/ozempic-coverage-important-work-perk

[3] Savings based on Scripius internal estimates of member use of Amjevita and Hadlima instead of Humira