Overview
Our client, an employer with approximately 8000 members and $9.75 million in annual prescription drug spend, was struggling to manage costs under their PBM program. They have provided prescription drug coverage with this large national PBM for more than six years and their contract included most of the PBM’s additional stand alone cost containment programs. Even so, with 8000 members trending a bit older, costs continued to accelerate.
The Process
After several meetings with their consultant, the group decided to carve out specialty prior authorizations, and contracted with ELMCRx Solutions to manage these claims. ELMCRx’s program for this client kept the incumbent formulary and PBM criteria in place, resulting in minimal impact on contract rebates.
Over the course of the first year of the carve out, the number of non-formulary approved medications was reduced by more than sixty percent, step therapy requirements and day/quantity limits were strictly enforced, and the plan achieved a 14% savings for specialty medications. This savings was achieved without any change in criteria or formulary and no loss of rebates. Simple enforcement of the PBM’s own criteria and policies, combined with a review of clinical documentation for each new and renewed prior authorization request led to much tighter monitoring of specialty medication approvals.
The Outcome
Based on the success of the first year and the limited concern expressed by members, the group has opted to continue using ELMCRx for their specialty medication approvals
DURING THE FIRST YEAR OF THE PROGRAM, THE GROUP ACHIEVED 14% SAVINGS ON SPECIALTY MEDICATIONS
