A Big Carrier Made Big Promises.
Guess Who Actually Delivered?
Questions to ponder:
Is it reasonable to expect an integrated carrier to manage pharmacy spend as tightly as they do medical?
With integrated carriers making large profits via ownership of specialty pharmacies, should they be relied upon to decide which high-cost prescriptions are appropriate?
How will you know if a pharmacy benefit is managed to lowest net cost in an arrangement that lacks transparency?
Home Healthcare Provider
Deep into the battle to tame drugflation
In 2016, battling rising pharmacy costs, a California-based self-funded home healthcare provider, with 1,600 members, turned to RxBenefits who managed their pharmacy plan effectively for five years.
Big talk. Illusions of a Miracle Cure
Like so many integrated carriers, the company’s former medical carrier liked to talk big. In 2021, they committed to further slashing pharmacy benefits through lower fees. Believing the promise from their trusted medical partner, they decided to carve back in.
So much for promises. Failed Remedies Disappoint
How did it go? Despite the carrier’s reduced fees, the company’s pharmacy plan costs continued to rise, from $60.25 per member, per month (PMPM) with RxBenefits to $90.21 PMPM with the carrier. The lower fees didn’t help to counter the effects of drugflation or address the root of the company’s problems: specialty spend.
Q1 2021*
(With RxBenefits)
$60.25 PMPM
36.8% Attributed to Specialty
*Q1 2021 based on last full quarter client was with RxBenefits
Q3 2022*
(With Carrier)
$90.21 PMPM
58.3% Attributed to Specialty
*Q3 2022 based on last full quarter of claims client provided for analysis while with carrier
Shortcomings of the Carrier Model: Critical Limitations with Costly Consequences
A focus on the medical benefit at the expense of sound pharmacy benefits management
No flexibility to customize the pharmacy plan according to plan-specific needs and goals
No transparency and visibility into plan data and performance
Limited use of available cost and clinical management programs to best impact high-cost specialty claims
From big talk to meaningful action. Finding a Sustainable Cure
The company knew who to turn to – or who to return to – to regain control and achieve its critical plan savings goals. In 2023, they re-engaged RxBenefits, opting to carve back out. Leveraging RxBenefits’ member-centric, pharmacy-focused approach, the transition unfolded seamlessly. The company regained flexibility along with data and contract transparency and restored independent clinical management to manage its plan to the lowest net cost.
Pharmacy costs fell dramatically
The benefits and finance teams felt more secure in the hands of a trusted partner.
Q1 2021*
(With RxBenefits)
$60.25 PMPM
36.8% Attributed to Specialty
*Q1 2021 based on last full quarter client was with RxBenefits
Q3 2022*
(With Carrier)
$90.21 PMPM
58.3% Attributed to Specialty
*Q3 2022 based on last full quarter of claims client provided for analysis while with carrier
Q3 2023*
(With RxBenefits)
$66.25 PMPM
44.7% Attributed to Specialty
*Q3 2023 based on first full quarter client was back with RxBenefits
Their RxBenefits Solutions
Read more about the specific clinical solutions implemented to help achieve lowest net cost.
Click on each dot to see each solution.
Independent Prior Authorization Management
PharmD-led reviews of high-cost prescription claims in context of chart notes to ensure prescribed medications are both clinically appropriate and cost-effective.
Complex Condition Intervention (CCI)
Reviews by medical doctors specializing in medication therapy for the treatment of more complicated chronic conditions.
Utilization Management for Next Generation Diabetes Drugs
Close oversight to protect members and employers against misuse of GLP-1s.
High-Touch Therapeutic Interchange
Specialists work with prescribers to identify cost-effective alternatives for high-cost specialty drugs.
Patient Assistance Solutions
Helping members find alternate sources of funding for high-priced specialty meds.
