A Big Three PBM’s specialty pharmacy approved $104,000 for 28 doses of Humira. Our clinical pharmacist reviewed the claim and determined that this could not be correct. After some back and forth with the PA Supervisor, it was determined that the reviewing pharmacist made an error. ELMC advised the PBM to correct the dosage and reduce the payment. The approved amount was reduced to 2 doses for a total of $7500.
Impact on Plan: A potential savings of $96,600.
During a standard review, our Clinical Pharmacist received a new start for Orencia. After reviewing the physician’s notes, it became apparent this therapy was an opportunity to discuss using a different medication with the provider. ELMC consulted with the physician who agreed that Enbrel mini would be an acceptable option for the patient. The patient has been on Enbrel for a year.
Impact on Plan: A savings of $52,630 in first year of treatment.
The increasing percentage of plan dollars allocated to pharmacy benefits has driven plan sponsors to seek ways to optimize the value of their spend. By better managing pharmacy benefits, plans sponsors can achieve cost efficiencies both inside and outside of the PBM structure. Faced with increasing costs and a dissatisfied employee population, a well-known Mid-Atlantic food manufacturer engaged AEC Rx Solutions to help rethink their prescription drug plan. This group’s demographics are consistent with many mid-sized self-funded employers.
Impact on Plan: By reconfiguring the Rx plan, the company has maintained a flat annual pharmacy spend.
