Advanced Utilization Management Programs Ensure the Most Cost-Effective Drug is Prescribed

In the portfolio of clinical products we offer, Advanced Utilization Management programs are the primary tool to managing patient utilization.
Utilization Management

Oil changes, tire rotations and inspections – when it comes to routine car maintenance, most people don’t think twice. To have optimized vehicle performance, regular upkeep is needed. Spending a few hundred dollars on regular oil changes can save thousands in engine repair costs down the road. Benefit managers may want to look at the pharmacy benefit program for their employees in the same way.

Patient populations shift overnight. It’s unpredictable when a member will be diagnosed with a costly, complex chronic condition or whether that member will respond to therapy. At the same time, new drugs are continuously coming to market and existing drugs are being approved for new conditions. Rapid population shifts and new drug price increases can happen in an instant.

Express Scripts helps plans ensure that the right tools are in place to protect a benefit’s budget from negatively affecting business. In the portfolio of clinical products we offer, Advanced Utilization Management programs are the primary tool to managing patient utilization. To make sure the safest, most cost-effective drug is chosen, and to ensure the proper use, selection, and amount of medication, we put in place these program offerings:

  • Prior Authorization which is the baseline for ensuring clinically appropriate use of a medication
  • Step Therapy which encourages use of front-line medications before second-line medications
  • Drug Quantity which aligns dispensing quantity with FDA-approved dosage guidelines as well as other clinical evidence

Right Strategy

The right strategy can not only protect a plan from a catastrophic shift, but also ensure clinically appropriate and effective use of new drugs as they come to market.

For example, in certain circumstances, the oral drug Iclusig (costing around $20,000 per month) is reserved for patients whose leukemia has not responded to other products in the same category. Through the Advanced Utilization Management program, a newly-diagnosed patient with a specific type of leukemia who is prescribed Iclusig will be directed to other less expensive medication recommendations for first time use. Treatment for this type of leukemia can last up to three years for a patient, potentially costing $700,000 for one patient’s treatment.

With Advanced Utilization Management, members will have access to the best therapy for them first, causing less financial impact to payers and patients as more people start on the right therapy from the beginning. These clinical checks are first developed through the lens of member care. Each check put in place will lead members to clinically safe and effective medications that cost less for both the plan and members.


This clinical-first approach is overlaid with a proactive strategy to managing market conditions. Express Scripts clinical experts are constantly monitoring the drug pipeline for future trends, new drugs coming to market and new indications for existing products. We regularly add new medications to lists so that your plan reaps the savings and stays ahead of new and potentially avoidable costs. There are four package tiers available within Advanced Utilization Management with additional medication lists included as plans move to the next tier.

In 2017 alone, this strategy, deploying our standard commercial rules, saved our clients nearly $3 billion. For example, a client with 56,000 lives implemented Advantage Plus Package and Adjunctive Specialty PA list in 2017 and saved $12 million for their plan.

Many employers have already taken the first steps and enrolled in the Limited package to have a safety net for their organization. After learning about the benefits of new implementations and updated lists, a majority of clients upgraded to a higher tiered package. These clients see more updates and significant savings throughout the year automatically.

Regular vehicle maintenance saves money in the long run and preserves the life of a car. It’s important to provide that same attention and preventative care to a plan’s pharmacy benefit program.

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