Practical Research that Identifies and Illuminates

[R5] The Actuarial Influence on Pharmacy Benefits

ACPE UAN: 0233-0000-19-043-L04-P | Contact Hours: 1.25 | Activity Type: Knowledge-based

Faculty(s)

• 

  Karl J. Gregor, PharmD, MS

  Vice President, Pharmacy Advisory Services
  Optum
  Fishers, Indiana
• 

  Drew Kirchner, FSA

  Senior Actuarial Director
  Cigna Healthcare
  Denver, Colorado
• 

  Whitney S. Pratt, FSA, CERA, MAAA

  Actuarial Manager
  Optum
  Englewood, Colorado

Moderator(s)

• SW

  Stephen E. Wolff, PharmD, ASA, MAAA

  Pharmacy Management Consultant
  Milliman
  Chicago, Illinois

Today, pharmacy costs are a higher percentage of the overall health care spend than in the past. The result is greater uncertainty in managing the financing of pharmacy benefits than ever before. To address this uncertainty, actuaries are now more active in designing pharmacy drug benefits, and are critical in projecting pharmacy costs, setting associated premiums, and influencing utilization management strategies. Actuaries also support various pharmacy stakeholders that must navigate complex operational, regulatory, and fiscal environments.

This session is designed to provide a fundamental understanding of actuarial roles, culture, language, methods and value drivers, and how they influence formulary decision-making and different lines of business.

Learning Objectives:

At the completion of this activity, participants should be able to:

1. Summarize the role of actuaries in managing the pharmacy drug benefit.
2. Define key principles needed by actuaries to project pharmacy costs, set premiums, and influence utilization management strategies.
3. Through a case study, explain how actuaries use specific data to impact the formulary decision-making.
4. Summarize the types of outcomes seen when actuarial data is utilized to influence the pharmacy benefit.
5. Describe actuarial influence in different settings (e.g., Health plan, pharmacy benefit managers, and specialty pharmacy) and lines of business (e.g., commercial, Medicare, Medicaid, and the individual market).