A school board located in the Midwestern United States with an average of 3,438 monthly members in 2019 had an annual pharmacy plan spend of $5.8 million. Unfortunately, the board’s overall pharmacy spending trend had increased steadily from $95.84 per member per month (PMPM) in the first quarter of 2019 to $164.44 PMPM in the fourth quarter of 2019 – averaging $141.14 PMPM for the year. Facing these increased costs, the board needed a strategic pharmacy benefits partner who could implement targeted, clinical-based pharmacy savings programs and provide ongoing guidance to help lower their annual pharmacy spend in a sustainable way.
RxBenefits applied the following Clinical Advantage Program (CAP) components to address the plan’s top risk areas and decrease pharmacy benefits costs for the school board:
- Low Clinical Value Medication Exclusions – Removing unnecessary medications from the formulary that are considered high-cost medications yet provide little-to-no clinical value compared to lower-cost alternatives.
RxBenefits removed a combination medication known as Duexis® that was costing the plan $2,400 for a 30-day supply. In its place, members received over-the-counter alternatives Advil and Pepcid that cost about $18 for a 30-day supply.
- High Dollar Claim Review – Conducting independent clinical reviews of high-cost claims that exceed $1,000 per month to ensure appropriateness following FDA-approved indications and dosages. Many times, these claims are redirected to lower-cost alternatives prior to the initiation of the review.
RxBenefits’ team of pharmacists reviewed the plan’s high-cost claims to determine their clinical necessity and identify any lower-cost alternatives. The plan’s top three most expensive medications, Gattex®, Epclusa®, and Kalyeco®, accounted for a combined annual plan cost of more than $1.28 million in 2019.
Overall Optimization Results:
Through a tailored combination of RxBenefits’ CAP strategies, the school board was able to reverse the trend of increasing prescription drug costs and deliver an improved pharmacy benefit program to its members. Over the first half of 2020, the school board was able to decrease their average plan spend significantly. The LCV program alone provided an estimated savings or cost avoidance of $29,704 over the first 6 months, while the High Dollar Claim Review program produced an additional $120,880 in estimated savings on reviewable non-specialty high dollar claims within the first 6 months of the year.