School System Sees Lower Costs and Quality of-Life improvements
The Challenge
A 3,438 member school system in the Midwest, was struggling to manage their more than $5.8 million annual pharmacy spend – $141 per-member-per month (PMPM). What made the situation even more challenging was that just one member’s use of Gattex®, a costly limited distribution drug for a rare disease, had been costing the plan $994,000 a year – $23 PMPM – for two consecutive years, accounting for 16% of the total budget.
The Solution
Seeking to lower their extremely high drug spend the school system chose to move their clinical management to RxBenefits and adopted our Protect™ suite of products. RxBenefits implemented a Complex Condition Intervention (CCI) as part of an overarching strategy to lower cost and help improve outcomes.
The program safeguards the health of members with severe complex or chronic conditions that require specialty medications or constant monitoring. RxBenefits pharmacists undertook a detailed review and found that the previous pharmacy benefit manager (PBM) had not been maintaining diligent clinical management and had not conducted the necessary prior authorization (PA) review to ensure that the member was on the right medication for their condition. Gattex is meant to be used for patients with short bowel syndrome who rely on total parenteral nutrition. The member had gastroparesis, which can occur in patients who have had diabetes for an extended period.
RxBenefits initiated a comprehensive peer-to-peer review with the prescribing gastroenterologist and internal medicine specialist including a thorough examination of the member’s clinical documentation, diagnosis, treatment history, dosing, and weight, and found that the member did not meet the prescribing criteria.
Positive Impact on Member’s Health and Well-being
Based on the findings, RxBenefits pharmacists advised the member to consult with their prescriber for an alternative medication. This not only saved the school system money on a very expensive drug, it also eliminated the need for daily medication injections and lowered the member’s risk for adverse events – including accelerating the growth of abnormal cells, intestinal obstruction, and biliary and pancreatic disease – leading to an improvement in their quality-of-life and overall well-being.
Conclusion
Thorough management and leveraging independent clinical experts to evaluate new and existing prescriptions can deliver savings and improve quality-of life for members by ensuring that the right member is receiving the right drug at the right price, as needed to treat their unique needs.
