Peer-to-Peer Review in Complex Condition Intervention Reduces
Plan Costs by 18%
Enhancing Financial Health
and Member Well-being
The Challenge
Off-label medication use—prescriptions for non-FDA-approved indications— poses risks to patients and increases pharmacy plan costs. A common example is Humatrope®, which is approved for treating growth hormone deficiency but often used off-label to boost growth in children without a medical need
The Solution
RxBenefits implemented Complex Condition Intervention (CCI), which helped identify the issue. CCI ensures high-cost medications are clinically appropriate and medically necessary by having independent pharmacists collaborate with condition specialists and conduct peer-to-peer reviews to verify that the right member is receiving the right drug at the right price.
CCI Ensures:
Appropriate Use: Aligns treatment with the latest medical standards.
Member Safety: Confirms correct dosing based on current weight and progression.
Cost Optimization: Eliminates unnecessary medications and costs.
Additional Oversight: Applies prior authorization where needed.
Specialized Attention: Offers superior service from pharmacists and specialists.
Savings and Safety
The peer-to-peer review determined that the children did not have a growth hormone deficiency, so the prescriptions were not clinically appropriate, eliminating $294,000 of unnecessary annual spend. Potential side effects from Humatrope include joint pain and increased skull pressure. For children without a growth disorder, these risks outweigh the benefits.
