Complex Condition Intervention’s Peer-to-Peer Review Shrinks Plan Spend by 18%

The Challenge

Off-label prescriptions can wreak havoc on a pharmacy benefit’s plan spend. When medications are used for non-FDA approved reasons, it can introduce unnecessary risk to the patient and excessive cost to the pharmacy plan. One of the medications that is commonly used off-label is Humatrope, which is indicated to treat a growth hormone deficiency that leads to an abnormally short stature with normal body proportions. However, it is sometimes prescribed to boost growth rates for children and adolescents who are shorter than average due to genetics, not a medical issue. This unapproved use can be dangerous and costly for the patient and the plan.

The Solution

Utilization management with an independent reviewer is critical in determining why a medication is being prescribed and identify what is needed from what is desired. After implementing RxBenefits’ High Dollar Claim Review with Complex Condition Intervention, one client discovered two members were receiving the growth hormone Humatrope. These two prescriptions for one medication cost the plan $294,000 per year, or 18% of their total annual plan cost.

High Dollar Claim Review (HDCR) with Complex Condition Intervention (CCI) puts the appropriate clinical oversight in place to confirm high-cost specialty medications are clinically appropriate, medically necessary, dosed appropriately, and contextually appropriate as part of an overarching strategy to improve the member’s health. The program safeguards the health of members with complex or chronic conditions, such as those that are more severe and require specialty medications or constant monitoring.

The CCI process includes a peer-to-peer review with a physician specialist with expertise in the specific condition and drug therapy to verify the prescription aligns with well-established clinical guidelines and best practices to optimize health outcomes for people suffering from those conditions or diseases.

CCI ensures:

  • Appropriate Use: Treatment aligns with practice and condition-specific guidelines based on the latest medical standards
  • Member Safety: Verifying that medications are appropriately dosed based on the member’s current weight and correct dose progression
  • Optimizing Cost Savings and Reducing Waste: Eliminating unnecessary medications and costs that result from inappropriate dosing or parity priced medications, which occur when a drug has the same cost per unit regardless of the strength
  • Additional Oversight: Applying prior authorization guidelines in rare situations where a specialty medication did not previously require it
  • Specialized Attention: Providing a superior service experience from a robust team of pharmacists and condition-specific physician specialists who review each medication for PA compliance

The Results

The two Humatrope prescriptions were reviewed in a peer-to-peer review due to the nature of the prescriptions and the conditions it treats. Upon review, the physician specialist reviewer determined that neither Humatrope therapy met the criteria for continued use due to not being prescribed for an FDA-approved use.

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18%

Reduction in Plan Spend

$294K

Annual Savings

But it’s about more than dollars.

Side effects of Humatrope include swelling, flulike symptoms, back pain, joint pain or fracture as the child’s body grows rapidly, and even increased pressure inside the skull. For children with a growth disorder, that risk could be worth it in the interest of the child’s health. For children from a short family whose parents would prefer that they be taller, pain and injury are a high price to pay. HDCR with CCI was able to spare the children that expense.