Comprehensive, independent clinical oversight for better outcomes at the lowest cost

RxBenefits Protect

Eliminate wasteful pharmacy spending while protecting members’ health and safety

Employers want to ensure their members can get the medications they need, so they can live healthy, productive lives – without unsustainable costs to the plan. RxBenefits Protect solutions are led by independent PharmDs, delivering clinical expertise, oversight, and intervention to ensure medications are appropriately prescribed and used while avoiding unnecessary, inefficient spending.

Plans lose 7-10% solely due to poor clinical management
Rayos is a delayed-release version of Prednisone -- at approximately 280x the price.

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 lower-cost, equally effective treatments are available. Members are still able to access the medications they need, while plan sponsors are protected against unnecessary spending.

Independent Prior Authorizations

Foundational Prior Authorizations

Independent, manual reviews of all required prior authorizations (for both traditional and specialty medications), checking against chart notes to make clinically sound decisions.

High Dollar Claim Review

PharmD-led reviews of particularly high-cost, non-specialty medications – those over $1,000 for a 30-day supply – to ensure medical necessity, appropriate use, and adherence to clinical best practices

Complex Condition Intervention (CCI)

Next-level protection for patients taking very expensive specialty medications, whether newly or previously prescribed. With CCI reviews, our PharmDs engage a condition specialist – an MD – ensuring the member receives the right drug, at the right dose and frequency, at the best price.

Utilization Management for Next Generation Diabetes Drugs

Utilization Management for Next Generation Diabetes Drugs is an added layer of protection against off-label prescriptions of newer Type 2 diabetes drugs. This enhancement fights the recent overprescription of GLP-1s like Ozempic® for weight-loss purposes by confirming the diagnosis and only approving the PA if it meets established criteria – protecting members from potential health implications and saving this limited supply of drugs for patients who really need them.

Expensive new-generation Type 2 diabetes medications like Ozempic and Mounjaro are increasingly being prescribed off-label for weight loss.
A woman holding a GLP-1 drug

High-Touch Therapeutic Interchange for Anti-Inflammatory Medications and Dermatologic Agents

High-touch therapeutic interchange for anti-inflammatory medications and dermatologic agents are two of the top drivers of specialty spend. Our Therapeutic Interchange for High-Cost Specialty Medications Program identifies members taking those classes of medications, whether recently or previously prescribed who are most likely to benefit from intervention. Expert specialty pharmacists proactively engage the member’s prescriber to discuss viable lower-cost, therapeutically equivalent alternatives for these high-priced drugs, helping them provide their patients the treatment they need while still saving money for the plan sponsor. Then our clinical pharmacists monitor and assess the patient’s response to the therapy over time to ensure they continue to benefit from the treatment.

Healthy members and a healthy pharmacy plan require comprehensive clinical oversight.
Talk to your Account Management team about protecting your clients’ plan with RxBenefits Protect.

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