Caring For Members Doesn’t Have to Lead to Wasted Pharmacy Spend

The pharmacy industry can feel confusing, cold, and conflicting for plan sponsors and members. Benefits advisor often see the complicated process of how drugs are distributed, the many motivations impacting the cost of treatments, and pharmacy benefit plan losses of five to 10 percent solely due to poor clinical management. While there are hurdles to finding cost-effective medications that help members live healthy lives, there’s also hope when independent, thoughtful humans look out for those on the track to better health.

The need for independent oversight is clear – particularly for the most vulnerable members with chronic, complex, and rare conditions.

Who’s in the Room Where it Happens?

Prescription decisions begin with the member and the doctor. The prescriber is focused on clinical outcomes, but they may not see the price tag behind their decisions or realize the influence of drug reps and advertisements have on their prescription pad. The patient is looking to improve their own personal health and relieve their symptoms, while the PBMs and manufacturers can influence the choices made in the room with direct-to-consumer advertising, formularies, and rebates. However, one important voice is missing – the plan sponsor, who is paying most of the cost.

In this room full of conflicting interests, your clients need someone in the conversation who is aligned with their needs and those of their members. Members need the right drugs, in the right dosage, at the right price, and your clients need someone to provide strong, independent clinical oversight to make sure this happens.

Finding the Best Health Outcomes at the Right Price

RxBenefits Protect is an independent clinical management solution that eliminates wasteful spending and reduces medical risk for members. Our independent clinical pharmacists remove high-cost, low value drugs from the formulary and work with prescribers to find equally effective – but far less expensive – alternatives.

Think of the prescription pad as though it were a checkbook. If someone were to write a check on the account of the employer for Humira, would cost about $66K a year before rebates, but if that same doctor wrote for Methotrexate, it would cost about $5K a year. If someone was writing a check from your checking account, which would you want them to write?

We treat a client’s checkbook like it’s our own, and we treat their members like they’re our family members. We want members to get the most cost-effective medications they need to drive the best health outcomes without costing the plan more than is necessary.

One of the ways we do this is with prior authorizations using chart notes, requesting information from the doctor about the patient’s diagnosis, age, weight, lab work, and other factors that can influence a prescription.

Twenty years ago, prior authorizations weren’t that impactful because drugs didn’t cost as much, and specialty drugs weren’t very common. But today, we have to be more diligent. Prior authorization reviews also ensure high-cost prescriptions are clinically appropriate, and when needed our PharmDs engage the expertise of physicians specializing in complex conditions to provide next-level protection for members on these expensive therapies.

We’re here as an advocate for employers and their members. Learn more about how the human touch makes an important difference.

Share It

Enjoy our latest blogs, white papers and news by signing up for our newsletter today!