A municipality located in the Northeastern United States experienced a substantial increase to its prescription benefits plan cost driven by the rise of specialty drug costs. In particular, its specialty medications plan design allowed members to meet their out-of-pocket maximum for the plan year, artificially. With more than 2,700 average monthly member lives and an average plan spend of $2.59 million, the group needed to optimize its pharmacy plan to control specialty costs with minimal member impact.
As the municipality’s pharmacy benefits optimizer (PBO), RxBenefits conducted an in-depth pharmacy analysis. Using RxBenefits’ proprietary data analytics tool, RxAnalyzer®, our clinical pharmacists were able to identify specific risk areas driving the plan’s high specialty drug spend and opportunities to manage specialty costs. Based on the results of the analysis, they recommended a targeted clinical strategy to maximize savings opportunities and prevent unnecessary spending on costly specialty medications:
- Manufacturer Assistance Programs for specialty medications — Enabled the municipality to maximize available manufacturer-based assistance funds and offset costs for certain specialty medications while protecting copay accumulators and reducing member out-of-pocket costs.
Overall Optimization Results:
Working with RxBenefits, the municipality achieved significant savings on high-cost medications. Through the Manufacturer Assistance Program, the municipality immediately decreased its specialty PMPM by $13.33 and protected the plan from $689K in specialty costs over two years. Additionally, members were able to enjoy drastically reduced out-of-pocket costs while the municipality ensured the accumulators accurately reflected what the members had paid.