A school system located in the Midwestern United States with 12,350 members had an annual pharmacy spend of $21.6 million, or $145.91 per member per month (PMPM). Faced with an escalating specialty drug spend, the group needed a strategic pharmacy partner who could implement targeted, clinical-based pharmacy solutions to lower their plan costs while maintaining member access to appropriate medications.
RxBenefits conducted an in-depth pharmacy analysis to identify the specific areas driving the plan’s high specialty drug spend. Using our proprietary data analytics tool, RxAnalyzer®, our clinical pharmacist team recommended targeted clinical strategies to maximize savings opportunities and prevent unnecessary spending on costly medications:
- 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
- Foundational utilization management review — Laying the groundwork for appropriate medication use and oversight by putting in place an independent, comprehensive review process
- High-dollar claim review — Providing umbrella protection for the school system and its members by guarding against unnecessary spending on high-cost medications
- Manufacturer assistance programs for specialty medications — Enabling the school system to maximize the available manufacturer-based assistance funds and offset costs for certain specialty medications while protecting copay accumulators
Overall Optimization Results:
Through RxBenefits’ in-depth clinical oversight, the school system was able to achieve significant savings and reduce its risk of exposure to unnecessary high-cost medications. Working with RxBenefits, the school system decreased their plan cost by $1.5M ($41 PMPM) after just one quarter. Focusing on the plan’s data enabled us to spot the trends and patterns impacting the plan’s escalating prescription drug spend and ensure that the plan utilized only the most clinically appropriate and cost-effective medications.