Lowering Plan Spend for a National Financial Group

With 1% of pharmacy claims now accounting for approximately 45% of cost, employers have an opportunity to utilize more advanced management strategies to optimize their prescription drug spending. However, deciding which strategies to implement requires visibility into the specific cost drivers that are impacting the pharmacy benefit plan.

Through a comprehensive analysis of a southern financial services organization’s claims data, we were able to pinpoint the risk areas and implement tailored a clinical management solution. Read how our approach helped limit the organization’s exposure to unnecessary spending, saving them $388K.

The Challenge

A national financial services organization based in Texas averages 500 members per month under its pharmacy benefit. With an annual pharmacy plan cost of $737K ($132.61 average cost PMPM), the organization needed an additional level of utilization management than it was getting under its pharmacy benefit manager. It needed a partner to provide transparent oversight to support its goals of having a more sustainable pharmacy benefit.


Annual pharmacy spend

The Solution

RxBenefits conducted a Comprehensive Pharmacy Analysis of the financial organization’s claims data and pinpointed the risk areas affecting the plan. The analysis concluded that the plan could benefit from clinical management programs to prevent unnecessary high-cost, low clinical value medications. Additionally, there wasn’t a program in place to review high-dollar claims above $1,000 to ensure clinical appropriateness before the claims were paid.

RxBenefits implemented a tailored solution to address the identified risk areas. The solution included three components of its tailored Clinical Advantage Program (CAP):

  • Formulary optimization with low clinical value drug exclusions – Preventing unnecessary drug spend by removing non-essential, high-cost, low clinical value drugs 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 – Providing umbrella protection by guarding against unnecessary spending on high-cost brand and specialty medications that had clinically appropriate lower-cost alternatives. Our clinical team provided additional oversight through prior authorization reviews for certain high-cost prescription drug claims. The organization gained insight into the specific drugs contributing to its monthly plan cost and was able to limit its exposure.

The Results

RxBenefits delivered significant results for the financial services organization. Through the CAP solution, the organization was able to optimize its prescription
drug program, increase its visibility into clinical cost drivers, and limit its exposure to unnecessary spending.

Overall Optimization Results:


Projected plan savings due to low clinical value drug exclusions; 1% of claims impacted


Projected plan savings due from high-dollar claim reviews on non-specialty medications


A 72% decrease of plan cost PMPM, within a one-year period

Total Savings:

  • 52

    Decrease in
    annual spend,
    $737K to $349K

  • $388K

    Reduced annual plan cost
    within one-year period