Removing $18.25 PMPM of Wasteful Rx Spending through Improved Clinical Oversight

The Challenge

An employer located in the southeastern United States with more than 3,700 covered employees and dependents had an annual pharmacy spend of $146.65 per member per month (PMPM). The group was facing increasing costs because of a steady stream of high-cost brand and specialty drug claims, as well as multiple high-cost, low clinical value medications hitting their pharmacy benefit. It needed a tailored solution to better manage their limited budget and ensure they were not wasting money unnecessarily on costly prescription drugs.


PMPM annual pharmacy spend

The Solution

RxBenefits’ team of pharmacy experts conducted a comprehensive pharmacy analysis to identify the group’s specific risk areas and recommend a data-driven strategy to address those areas. The following Clinical Advantage Program (CAP) components were implemented:

  1. Formulary optimization with low clinical value drug exclusions – Preventing unnecessary drug spend by removing non-essential, high-cost drugs with low clinical value from the formulary
  2. Foundational utilization management review – Laying the groundwork for appropriate medication use and oversight by putting in place an independent, comprehensive review process using a team of licensed clinical pharmacists
  3. High dollar claim review – Providing umbrella protection by guarding against unnecessary spending on high-cost brand and specialty medications
  4. Manufacturer assistance program for specialty medications – Enabling the plan to maximize the available manufacturer-based assistance funds and offset costs for certain specialty medications while protecting copay accumulators

The Results

Overall Optimization Results:

Through RxBenefits’ technology-enabled solution, the group was able to better manage the utilization of high-cost drugs and address the low clinical value medications hitting the pharmacy plan. The targeted clinical programs put in place helped the group limit its exposure to costly medications and ensure only the most clinically appropriate and cost-effective medications were being utilized by plan members.


saved annually by excluding low clinical value drugs


savings annually on non-specialty drugs from high dollar claim reviews


savings per year on specialty drugs from the manufacturer assistance program and independently managed prior authorizations


PMPM reduction in average overall drug spend