How Clinical Rx Management Protects Members & Plan Sponsors

Top 3 Things You’ll Learn

  1. Why it’s necessary to review high-cost prescription drug claims for clinical appropriateness
  2. Five examples of prescription drugs causing wasteful pharmacy benefit spending
  3. How utilization management oversight and intervention helped lower pharmacy benefit costs

When someone is using a specialty medication, the inclination is to think that they have a severe condition, they are seeing a specialist, and the prescribed medication and the dosing are appropriate. Unfortunately, this scenario isn’t always true, which can be an alarming realization for a self-funded employer, considering that specialty drugs can be 12 times more expensive than the average annual cost of brand-name prescription drug therapy. In fact, the average annual cost of 61 specialty drugs widely used for treating chronic conditions reached roughly $79,000 in 2017. Having a clinical mechanism in place to review the appropriateness of these high-cost medications is a critical component to maintaining a sustainable pharmacy benefit plan.

The average annual cost of 61 specialty drugs widely used for treating chronic conditions reached roughly $79,000. The stakes are high for both the members and plan sponsors. Data-driven clinical oversight is a proven mechanism to ensure appropriateness and Rx plan sustainability.

Consider these examples that the RxBenefits clinical pharmacist team uncovered through its detailed claims review process:

Case #1: Human Growth Hormone

When medications are prescribed for non-FDA (U.S. Food and Drug Administration) approved reasons, it can be dangerous and costly for the patient and the plan. Without adequate utilization management, employers risk facing potentially devastating costs over unnecessary medications that can endanger their members.

A recent RxBenefits clinical evaluation found that two members were receiving the growth hormone Humatrope. Humatrope is sometimes prescribed to increase growth rates for children and adolescents who are shorter than average height due to genetics, not a medical condition. Through RxBenefits’ High Dollar Claim Review with Complex Condition Intervention, one client found that two members were receiving Humatrope prescriptions. These two claims accounted for 18% of the total annual plan cost. RxBenefits’ Complex Condition Intervention and peer-to-peer review with a physician specialist determined that neither Humatrope therapy was appropriate for continued use, as they were not prescribed for FDA-approved reasons.

Case #2: Parity Pricing

When a medication is parity priced, the drug cost is the same regardless of the dosage strength. Manufacturers use parity pricing tactics to quietly increase drug costs, causing unsuspecting plan sponsors to risk overpaying for drugs that add no additional value for the member.

A medication that uses this tactic is Imbruvica. In a clinical evaluation of high-cost claims, RxBenefits identified a single Imbruvica claim affected by parity pricing that was costing the client $13,771 every 28 days. RxBenefits’ clinical experts and Account Management Team worked together to optimize the dosing, switching the member to a more appropriate regimen and saving the client over $4,000 a month.

Case #3: Hereditary Angioedema

A clinical evaluation of a prescription drug claim for a member with hereditary angioedema included a review of two medications used to treat that condition, which is not uncommon. Normally we would expect to see a person on prophylactic therapy with Haegarda® or with Takhzyro®. In addition to that, they would typically have a medication for any acute attacks that they might have. Firazyr® is the one that is most commonly used.

In this particular case, though, the member was not on prophylactic therapy and instead was taking two acute medications. This is not clinically appropriate and does not align with standards of practice nor the FDA recommendations. It was appropriate to redirect that member to a therapy regimen that is going to be more sustainable for them to prevent attacks. The member’s treatment plan was addressing the sequella of the disease, instead of treating the underlying condition. Intervening in this scenario is a good service for the member to make sure they have a more appropriate therapy as well as for the employer because there is a cost-benefit involved in the switch.

Case #4: Acromegaly

Another situation occurred with a member using a medication called Somatuline® to treat acromegaly. The member was receiving four times the recommended medication dose that they should have, likely because of a simple mistake in the pharmacy’s system. Through a clinical intervention from the RxBenefits clinical team, the physician’s office was contacted.  The physician verified that the dosing should be reduced and then worked with the pharmacy to update the prescription.

The cost-avoidance for the plan was substantial – more than $200,000 per year from that single claim. More importantly, the appropriate medication dose was provided to the member. The member’s drug regimen changed from four syringes per month (one per week) to one per month, which is a significant change for the member’s quality of life. A mistake could have occurred in the transfer of information, but the point is that this intervention resulted in a better outcome for everyone involved.

Case #5: Short Bowel Syndrome

During a large case review, the RxBenefits clinical team discovered an issue with a member taking Gattex® for short bowel syndrome. Gattex is prescribed on a weight-based dosing regimen, and the medication comes in 5mL vials, but there is only 3.7mg in each vial. Each vial costs more than $40,000. In this case, the doctor’s prescription was based on this particular member’s weight, which was calculated to need 3.8mg, and so the patient needs two vials per month for their dosing. However, people with short bowel syndrome can have fluctuations in weight.

The RxBenefits clinical team flagged this claim and reached out to the physician. The clinical review found that the member had in fact lost weight, and only one vial was needed to meet the specific dose requirements of the medication. Optimizing this dose saved the plan $40,000 per month. This example shows how important it is, especially with weight-based medications, to be diligent in understanding where the breakpoints are for dosing and to stay in contact with the member and physician to maintain appropriate dosing at all times.

Employers want to do the best that they can for their employees. A data-driven clinical oversight strategy that uses detailed data analytics, appropriate authorizations, and independent pharmacist reviews can help your clients optimize the clinical and economic value of their pharmacy benefit plan.

See additional examples of how clinical oversight and utilization management helped employers improve medication appropriateness and eliminate wasteful spending.

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