A manufacturer with over 4,700 members in the Western United States was unhappy with their pharmacy arrangement and needed more expertise to help curb spend. Their plan was not protecting them from rising spend and high-dollar claims, and they did not have the support they needed from their PBM. The company needed a new pharmacy benefits partner who was an expert in the space and willing to look at their plan with a critical eye.
RxBenefits conducted an in-depth analysis of the manufacturer’s contract and plan design. Our clinical pharmacists were able to identify specific risk areas that
could be optimized to minimize their costs using RxBenefits’ proprietary data analytics tool, RxAnalyzer®. They then suggested a tailored clinical and plan design strategy to maximize savings:
- Narrowing the Formulary – Offers better pricing and additional oversight on covered medications to maximize the use of plan dollars with limited member disruption
- Formulary Optimization with Low Clinical Value Drug Exclusion – Prevents unnecessary drug spend by removing non-essential, high-cost,
low clinical value medications 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
- Manufacturer Assistance Program for Specialty Medications – Provides umbrella protection against unnecessary spending on high-cost medications by providing an independent pharmacist review of claims greater than $1,000
Our clinical team provided additional oversight through prior authorization reviews for certain high-cost prescription drug claims, giving the organization
insight into the specific drugs contributing to its monthly plan cost and was able to limit its exposure
Overall Optimization Results:
RxBenefits’ plan design and clinical optimization resulted in significant savings for the manufacturer. Through the Clinical Advantage Program and plan design changes, they saved an additional 19% over expectation, resulting in $719K savings in plan cost over two years. This ensured the company’s pharmacy dollars paid for the most cost-effective, clinically appropriate therapies for its members, and they knew they had a pharmacy expert watching their plan to suggest any necessary changes.