Driving Out Wasteful Rx Spending with Data-Driven Clinical Oversight

The Challenge

A trucking logistics company based in the Southern Central region of the United States averaged 2,260 members per month under its pharmacy benefit program, with a 62% member utilization rate. The company had an annual pharmacy plan cost of $1.28 million, or $47.26 per member per month (PMPM). The organization needed a sustainable solution to address its increasing exposure to high-cost and low clinical value medications that added up to more than $5 PMPM in unnecessary spending.

The Solution

RxBenefits conducted a Comprehensive Pharmacy Analysis of the trucking company’s claims data. The analysis pinpointed the specific risk areas driving the plan’s high prescription drug costs so that RxBenefits’ team of pharmacists could recommend appropriate strategies to optimize the company’s pharmacy benefits program.

RxBenefits’ tailored solution included two components of our tailored Clinical Advantage Program (CAP), designed to prevent unnecessary spending on high-cost, low clinical value medications, and ensure the clinical appropriateness of prescriptions before the claims were paid.

  • Formulary Optimization with Low Clinical Value Drug Exclusions Preventing unnecessary drug spend by removing non-essential, high-cost, low clinical value medications from the formulary.

Our clinical team continually monitored drugs in the market and updated the low clinical value drug list throughout the year, which produced additional value.

  • High Dollar Claim Review (HDCR) – Providing umbrella protection against unnecessary spending on high-cost medications by providing an independent pharmacist review of claims greater than $1,000.

Our clinical team’s oversight provided the trucking company with insight into the specific drugs contributing to its monthly plan cost and helped limit its spending to clinically appropriate medications.

The Results

Overall Optimization Results:

RxBenefits’ data-driven clinical oversight delivered valuable results for the trucking company. Through our CAP solution, the organization gained greater insight into the high-cost prescription drugs utilized by members. This increased visibility enabled the company to ensure its pharmacy dollars paid for the most cost-effective, clinically appropriate therapies for its members.


total cost avoidance over one year


PMPM decrease in plan costs from LCV and HDCR programs combined