Clinical Utilization Management
Comprehensive, independent clinical management for better outcomes at the lowest cost
Eliminate wasteful pharmacy spending while protecting members’ health and safety
Employers want to ensure their members can get the medications they need at an affordable price so they can live healthy, productive lives – without incurring unsustainable plan costs. RxBenefits’ team of independent PharmDs delivers clinical expertise, utilization management, and guidance to ensure medications are appropriately prescribed and used while avoiding unnecessary, inefficient spending.
Clients see a 7:1 ROI on clinical programs
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.
Foundational Prior Authorizations
Unlike PBMs, where claim reviews are automated and approved nearly 90% of the time, our clinical team conducts manual reviews to make sure members get appropriate medications to drive positive outcomes at the lowest possible cost.
High Dollar Claim Review
PharmD-led reviews of particularly high-cost, non-specialty medications – those typically 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 high-cost specialty medications, whether newly or previously prescribed. With CCI reviews, our PharmDs have the ability to 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 GLP-1s
Utilization Management for GLP-1s is an added layer of protection against off-label prescriptions of drugs like Ozempic® and Mounjaro®. These high-dollar drugs, originally prescribed for type 2 diabetes and known for their weight-loss effects, have received FDA approval for a host of additional indications. Now more than ever, careful management of these medications is critical to prevent off-label use, control wasteful spending. ensure medical necessity. and protect members from potential health implications.
High-Touch Therapeutic Interchange for Anti-Inflammatory Medications and Dermatologic Agents
Anti-inflammatory medications and dermatologic agents are two of the top drivers of specialty and overall plan spend. Our High-Touch Therapeutic Interchange identifies members taking those high-cost medication classes who are most likely to benefit from assistance. Expert specialty pharmacists proactively engage the member’s prescriber to discuss viable lower-cost, therapeutically equivalent alternatives. This ensures patients get the treatment they need while still saving money for the employer. 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 management.
