A non-profit company based in the northeastern United States with more than 500 members was faced with increasing drug costs each month. The employer averaged an annual pharmacy spend of $1.2 Million and a per member per month (PMPM) cost of $192.16. They needed a sustainable solution to combat the monthly rising costs while addressing a proactive approach to high-cost, non-specialty drugs and low clinical value
drugs that had contributed to wasteful spending.
RxBenefits’ pharmacy experts completed an extensive pharmacy analysis of the company’s claims data. The expert team of pharmacists were able to uncover that the pharmacy benefits plan was experiencing high prescription drug costs. RxBenefits recommended that the best course of action was to create an optimized, proactive approach to the monthly rising costs of non-specialty and low clinical value drugs.
The recommended strategy included RxBenefits’ Clinical Advantage Program (CAP), a program designed to prevent unnecessary spending on high cost, low clinical value drugs while improving clinical strategy, and dosage and utilization management. RxBenefits tailored the program by using two of its components to best fit the employer’s needs.
- Formulary Optimization with Low Clinical Value Drug Exclusions – Avoided unnecessary drug spend by eliminating non-essential, high-cost, low clinical value medications from the formulary.
RxBenefits’ clinical team monitored drugs on the market and revised the low clinical value drug list throughout the year. This produced more savings for the non-profit organization.
- High Dollar Claim Review (HDCR) – Provided umbrella protection against unnecessary spending on high-cost medications by offering an independent pharmacist review of claims greater than $1,000.
RxBenefits’ analysis provided insights into which drugs were causing substantial costs to its monthly cost spend.
RxBenefits was able to provide valuable data-driven insights to help lower monthly and overall costs for the non-profit organization. Using the Clinical Advantage Program allowed the employer to better understand high-cost medications and their utilization among members. The organization received lower costs but also more clarity into their pharmacy benefits plan to ensure proper spending and cost-effective, appropriate
clinical therapies for members.