The Industry’s Most Comprehensive Clinical Approach to Utilization Management

Independent PharmD Oversight for the Best Outcomes at the Lowest Cost

RxBenefits Protect solutions deliver independent clinical expertise, oversight, and intervention to eliminate wasteful spending while protecting the health and safety of plan members. Protect programs are designed and led by independent PharmDs to ensure clinically appropriate drug use and avoid unnecessary, inefficient spending. We want members to get the most cost-effective medications they need to drive the best health outcomes so that they can live healthy and productive lives without costing the plan more than is necessary.

Plans lose 7 – 10% solely due to poor clinical management

Low Clinical Value (LCV) Formulary Exclusions 

A good price on the wrong drug is still a waste of money. Low Clinical Value Formulary Exclusions identify and remove high-cost drugs from the PBM formularies when a lower-cost, equally effective medication is available. Members are still able to access the medications they need, while plan sponsors are protected against unnecessary spending.

High Dollar Claim Review (HDCR)

Our independent team of licensed experts manages the clinical review process for high-dollar claims – claims that are automatically flagged for exceeding $1,000 for a 30-day supply. Each of those claims is examined by one of our PharmDs, who reviews medical documentation, prescribing information, and data from our own system to determine whether the prescription is being used effectively and in accordance with FDA guidelines.

3%
of members that take a high-cost brand, and specialty medications account for over half of plan costs

Complex Condition Intervention (CCI)

Members with chronic, complex, and rare conditions are some of the most vulnerable and in need of oversight and protection. But the high-cost specialty medication used to treat those conditions can drive cost significantly for plan sponsors. CCI provides an additional level of oversight for very high-cost specialty drugs – typically, those that exceed $250,000 per year. In addition to the standard HDCR review, our PharmDs consult with a condition specialist to make sure the prescription is for the right drug, in the right dose, at the best possible price.

Enjoy our latest blogs, white papers and news by signing up for our newsletter today!