Clinical Optimization Breathes Life into Health System’s Pharmacy Benefit

The Challenge

A hospital system with over 1,300 members was managing very high annual pharmacy costs and an excessive PMPM. With such high spending, it was looking for ways to reduce the impact of high-cost and low-value medications on the plan while minimizing member disruption. The health system needed a partner with proven experience in benefit optimization to assist in finding ways to improve employee health while balancing the main challenges that a hospital system faces with its pharmacy benefit.


annual pharmacy spend



The Solution

After conducting a Comprehensive Clinical Pharmacy Analysis using RxBenefits’ proprietary data analytics software, RxAnalyzer, the experienced RxBenefits Strategic Markets and Clinical Services teams knew how to tailor the hospital system’s pharmacy benefits to achieve its goals. The solution included implementing a combination of components from RxBenefits’ Clinical Advantage Program (CAP) to reduce the number of high-cost claims with the lowest member impact.

  • Formulary Optimization with Low Clinical Value Drug Exclusion prevented unnecessary drug spend by removing non-essential, high-cost, low clinical
    value drugs from the formulary.
    RxBenefits’ clinical team continually monitored drugs in the market and updated the low clinical value drug list throughout the year, which resulted in additional value for the health system.
  • High-Dollar Claim Reviews provided umbrella protection by guarding against unnecessary spending on high-cost brand and specialty medications.
    RxBenefits’ clinical team provided additional oversight for high-cost prescription drug claims. The health system gained insight into the specific drugs contributing to its monthly plan cost PMPM and limited its exposure to unnecessary spending on medications that had clinically appropriate lower-cost alternatives.
  • Manufacturer Assistance Program for Specialty Medications enabled the health system to maximize the available assistance funds and offset costs while protecting its plan design.
    RxBenefits tracked each member’s true out-of-pocket expenses while applying manufacturer dollars to reduce both the plan’s and members’ costs.

The Results

Overall Optimization Results:

By adjusting its clinical programs, the health system was able to achieve significant savings. RxBenefits’ Clinical Advantage Program allowed it to achieve its goal of improving employee health with minimal member disruption, all designed specifically for hospital clients.

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