Specialty medications account for a disproportionate share of prescription costs and are the most significant pharmacy plan drivers today. In fact, 1 in 10 employers will have a member whose condition leads to more than $250K in annual medication therapy costs. It is essential to understand that members on specialty medications frequently have a complicated health history with complex disease states. Therefore, plan sponsors must have a strategy in place beyond the typical automated review processes the PBMs use, especially for complex conditions – one that validates medical chart notes to ensure the plan only pays for appropriate medications and redirects members to appropriate alternatives when necessary.
A mid-sized school system located in the Midwestern United States had an annual pharmacy spend of more than $5.8M, or $141 per member per month (PMPM). A single member utilizing Gattex®, an expensive limited distribution drug (LDD), had been driving 16% of the plan spend, or $23 PMPM. The prior pharmacy benefit manager (PBM) did not require a prior authorization (PA) on the medication to validate utilization. This resulted in annual spend of $994K for two years running and was on pace to hit that again.
RxBenefits’ team of clinical pharmacists identified utilization of Gattex as a potential risk area for the school system because the previous PBM did not require a prior authorization review to validate the member’s condition matched the drug’s indications. RxBenefits could not immediately confirm clinical appropriateness and wanted to ensure that the prescription aligned with well-established clinical guidelines and best practices. Upon identifying the claim, and after receiving school system approval, RxBenefits’ clinical pharmacist team administered the following interventions:
- Initiated a peer-to-peer review with the prescribing physician (gastroenterology and internal medicine specialist)
- Gathered and reviewed clinical documentation of diagnosis, treatment course, dosing, and weight
Overall Optimization Results:
Through RxBenefits’ detailed clinical review process, the medication was deemed inappropriate for the member’s diagnosis. Gattex is medically necessary for patients with short bowel syndrome who are dependent on total parenteral nutrition (TPN) and who are shown to have a decrease in TPN requirement. Based on the clinical information provided, the patient had neither been diagnosed with short bowel syndrome nor had documentation of prior treatment history showing a reduction in parenteral nutrition.
After consultation with the school system, the member was alerted that the medication was not appropriate and advised to talk with their prescriber for an alternate medication. This intervention eliminated wasteful spending for the school system, leading to an almost 16% annual plan savings.