Programs
Our Tesser Rx Cost Containment programs offers a unique method of eliminating cost from the pharmacy benefit delivery system through the proper program design, control of costs and clinical utilization. Our objective, unbiased review provides best outcomes for the plan sponsor and member.
Management
Specialty drugs drive 40-50% of employer Rx cost but represent less than 5% of total prescription volume. Our clinical pharmacists work with plan sponsors, TPAs, health plans to provide comprehensive management serious conditions and high-cost claims.
Cost Containment
Programs
Our Tesser Rx Cost Containment programs offers a unique method of eliminating cost from the pharmacy
benefit delivery system through the proper program design, control of costs and clinical utilization. Our
objective, unbiased review provides best outcomes for the plan sponsor and member.
Non-Specialty
Cost Containment Programs
Tesser Rx helps plans reduce their drug costs and improve medication compliance. Our program offers a user friendly way to help employees reduce their out-of-pocket costs.
the needs of a wide variety of partners:
- Traditional Self-Insured Plan Sponsors
- Municipal and Labor Groups
- PBMs that want to provide full transparency to their clients
- Stop Loss Carriers striving to mitigate prescription drug related lasers and specific claims
- Medicare Advantage Carriers
- Reseller
- White Label
- Grey Label
- Enterprise/Custom
The Non-Specialty Rx Cost Containment Program takes a quantitative approach to managing prescription drug costs. With an ongoing phased process, we determine which medications can be managed, coordinate outreach with prescribers and members, and monitor medication changes. Our program does not require benefit plan changes and can be implemented at any time during the plan year.
High Cost & Specialty Medication
Cost Containment Services
Specialty drugs drive 40-50% of employer Rx cost but represent less than 5% of total prescription volume. The largest specialty pharmacies are owned by PBMs and a key driver for their earnings growth. It is wise to evaluate the effectiveness and appropriateness of clinical management for these high-cost medications.
80% of all drugs recently approved or under development could
be classified as
specialty drugs.
CLASSIFIED AS
SPECIALTY DRUGS
its regimented process
- Each PA is scrutinized by a clinical pharmacist from start to finish
- Pharmacists work collaboratively with prescribers leveraging their clinical • experience and latest clinical references each step of the way
- Pharmacy techs handle inquiries about clinical records, review status and • enter initial PA information in the system. They do not play a role in the • decision regarding a review.
- Disciplined review and audit occurs within each client’s specific
- turn around time
- Vast majority of reviews completed within 48 hours, 24 hours
- for urgent reviews
$96,600
POTENTIAL SAVINGS
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.
$53,000
ANNUAL SAVINGS
Pulls review from PBM queue and enters it into ELMCRx processing system
Reviews the PA to verify:
- PA meets criteria
- Medication is on the formulary
- Any required steps were followed
- Medication is FDA approved
- Any off-label use is supported by clinical documentation
- All required tests were completed before prescribing
- Verifies dosage, weight, body mass, surface area
- Verifies quantity limits
- Determines if the medication can be managed to a clinically equivalent
- alternate, that is on the formulary and less expensive
Enters completed review and any documentation into PBM queue for processing by PBM
Plan Sponsors are acutely aware of the increasing cost of providing critical prescription drug coverage to their employees. Part of this increase in cost is driven by the number of new medications coming to market. The FDA approved 48 novel drugs in 2019 and 53 in 2020 with the majority of these drugs classified as Specialty. Generally speaking, these “new to market” medications are more expensive alternatives to currently existing therapies. This trend will not abate.
NOVEL DRUGS
IN 2019
NOVEL DRUGS
IN 2020
Clinical
Management
Mary Ann Carlisle - 484.433.1412
It is well known that patients with chronic conditions do not take their medications as prescribed. This is a result of any number of factors including cost, side effects, inability to get/pick up prescriptions, lateness on refills or other reasons, such as difficulty in swallowing pills.
With between 25% and 40% of patients “non-compliant” or “non-adherent”, conditions tend to progress creating the need for additional medical treatment.
ELMCRx’s Medication Adherence Program connects our knowledgeable, compassionate pharmacists with members to provide counseling, education and one on one
- Initial Outreach to “at risk” members via sms/text, emails and automated call
- Secondary outreach to members via live call from pharmacist who has extensive knowledge about the class of medication
- Follow up assistance based on member input Success is monitored each month via follow up contact with the member and analysis of claim reports for confirmation that the medication was filled.
o Cost – we assist with more cost effective options by working with prescriber and contacting pharmacy about copay cards
o Concern about side effects – we review these with the patient and contact the prescriber to make them aware of the patient’s concerns
o Lack of understanding about the therapy – we review the goals of the therapy and the time that it might take to achieve the desired outcome
o Lack of symptoms – we review the course of the therapy with the patient and stress the importance of completing the therapy, unless there are side effect concerns
Success is monitored each month via follow up contact with the member and analysis of claim reports for confirmation that the medication was filled.
$450,000
ANNUAL SAVINGS
During a routine review, our clinical team detected an unusually high dosage for a hemophilia treatment. The prescribing physician agreed with the findings and altered the medication from Factor to MAB, improving patient safety and compliance, while maintaining clinical efficacy of the treatment.
Impact on Plan:
The annual costs was reduced from $1.2 million to $750,000 in the first year, and $700,00 in next year, a savings of $950,000 over two years.
ELMCRx team of experienced clinical pharmacists work with plan sponsors, TPAs, health plans to provide comprehensive management serious conditions and high-cost claims. We work directly with prescribers to manage high-cost medications and conditions such as:
- Myalept (Lipodystrophy)
- Mavenclad (Multiple sclerosis)
- Takhzyro (HAE)
- Juxtapid (Homozygous
familial hypercholesteremia)
- Cinryze (HAE)
- Icatibant (HAE)
- Haegarda (HAE)
- Orladeyo (HAE)
- Spinraza (Spinal muscular atrophy)
- Orkambi (Cystic fibrosis)
Payers want to optimize treatment for these serious conditions and ensure that plan resources are used to help obtain the best outcome for patients. Our Clinicians establish a working relationship with prescribers and use the most current clinical resources to evaluate the efficacy of proposed treatment plans. We currently serve:
- Traditional Self-Insured Plan Sponsors • Municipal and Labor Groups
- Municipal and Labor Groups
- Middle Market PBMs who want to offer superior cost containment services
- Stop Loss Carriers striving to mitigate prescription drug related
- Medicare Advantage Carriers
Experts agree that of all the tools pressed into service to help manage rising prescription benefit program costs, in-depth clinical management is the most critical. Experienced clinical pharmacists, certified in various sub-specialties, provide our clients with insightful clinical management. Managing claims for life-saving therapies, requires thoughtfulness, clinical acumen and a commitment to being thorough. These are the qualities found in the ELMCRx Clinical Pharmacy team.
How Does the Clinical Management Program Work?
- Experienced pharmacists review and manage high-cost success stories for clients
- Complete review of all clinical records, tests and medications
- Pharmacists engage directly with prescribers on each success stories
- Emphasis on high-cost/high-exposure success stories such as HAE, hemophilia,
muscular dystrophy, etc.
Focusing on Vial Management Protects Plans From Excessive Costs
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