Making Pharmacy Benefits More Affordable for a School System

The issue of prescription drug affordability is not new to the world of employee benefits. However, the growing prevalence of high-cost medications has put increasing pressure on employers to lower costs of employee healthcare benefits.

Now, with the additional financial challenges brought on by the coronavirus COVID-19 pandemic, those pressures are likely to grow exponentially, especially for employers in the public sector. See how we helped a school system construct a tailored clinical solution to lower their pharmacy benefits costs while maintaining member access to appropriate medications.

The Challenge

A school system located in the southern United States with 7,600 members had an annual pharmacy spend of $9.96M. The plan’s per member per month (PMPM) cost was $109.64 and was on track to increase to $124 PMPM.


Annual pharmacy spend

The Solution

Our clinical team designed and implemented our Clinical Advantage Program (CAP) solution to address the organization’s specific risk areas as identified in our claims analysis. The CAP solution contained a mix of these targeted components:

  • 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
  • Foundational utilization management review – Laying the groundwork for appropriate medication use and oversight by putting in place an independent, comprehensive clinical review process
  • High-dollar claim review – Providing umbrella protection for the school system and its members by guarding against unnecessary spending on high-cost medications
  • Manufacturer assistance programs for specialty medications – Enabling the school system to maximize the available assistance funds and offset costs for certain specialty medications while protecting their plan design

The Results

Overall Optimization Results:

Through our tailored CAP solution, the school system was able to increase its clinical visibility and optimize its prescription drug program. Focusing on the plan’s specific risk areas enabled us to help the school system limit its exposure to high-cost drugs, which resulted in a more affordable and more sustainable pharmacy benefit.


Reduced Annual Drug Spend
from $9.96M


savings ($27 PMPM) in plan
cost after just one month


Net savings during
a 12-month period