A specialty prior authorization is an authorization by a PBM that allows a pharmacy to dispense a medication based on specific clinical criteria. However, if the medication quantity and day supply are not reviewed on a regular basis or accurately, there is a chance that the pharmacy may fill the medication more frequently or in a greater quantity than the PBM or provider expect. The most commonly impacted medications are packaged in vials. Higher quantities or an uncommon day supply should be reviewed consistently to ensure that the medication is being dispensed according to the prescription directions, typical dosing patterns and clinical criteria. Failing to closely monitor these areas can lead to excessive cost and waste.
$110
THOUSAND
ANNUAL COST SAVINGS
Our client, a Third Party Administrator owned by a Top 5 national brokerage firm, recently requested a comprehensive review of a Haegarda patient who had been on the medication for two years. Their concern was that the medication was being dispensed without proper attention to the patient’s clinical records.
In early 2020, the prescriber submitted a prescription for Haegarda to the pharmacy. The directions on the prescription indicated that the patient should receive 5000 units twice each week, every 3 to 4 days, and directed the pharmacy to dispense a 30-day supply. This medication is typically dosed twice every 7 days. Based on these directions, the quantity filled for the patient would be 8 vials of Haegarda 2000 units and another 8 vials of Haegarda 3000 units every 28 days.
ELMCRx requested a copy of all medical records for the patient, including a copy of the original prescription and the records of all medication fills. Upon review, it was discovered that the pharmacy dispensed 10 vials of Haegarda 2000 units and 10 vials of Haegarda 3000 units every 30 days from January 2020 until October 2020, not the appropriate 8 vials. As a result, the patient accumulated an extra 2 vials of each strength per month at a cost of $12,286 per month. Over the 9 month period that the patient was taking the medication, the cost for the extra medication was $110,574
Ultimately, the patient accumulated 18 vials of each strength that could neither be used nor the returned to the pharmacy. Our client leveraged the ELMCRx review to help recover the excess payment for from the PBM. This is one of many examples that demonstrates the importance oversight plays in preventing waste in your pharmacy spend.
