A mid-sized health system located in the northeast United States had an annual spend of more than $7.9 million, $120.43 per member per month (PMPM). A
single member utilizing the medication Afinitor Disperz accounted for $65,000 per month, or $6.18 PMPM, with more than $400,000 in spend accrued over the
five months between November 2019 and April 2020. This one claim for Afinitor Disperz 2mg resulted in the member receiving a quantity of 119 tablets every 28 days to achieve the prescribed daily dosing. The parity pricing had gone unnoticed by the pharmacy benefit manager (PBM) and its reviewers, the physician, and the pharmacy.
Upon identifying the claim, the RxBenefits team of clinical pharmacists quickly intervened to optimize the dosing of this claim. We initiated a peer-to-peer review with a specialized physician. Our joint evaluation concluded that the daily 8mg dose could be optimized, safely switching the member from taking four 2mg tablets daily to taking one 3mg and one 5mg tablet daily. This switch would reduce the number of units daily by half, thereby cutting the cost in half as well.
RxBenefits worked with the prescriber to successfully redirect the high-cost prescription drug claim to a lower-cost option that meant fewer pills for the member to take each day. Our dose optimization intervention helped the health system reduce unnecessary spending for this claim, lowering its projected overall pharmacy benefit plan costs for the year.
Overall Optimization Results: