One pharmacist. One year. $2.7 million savings.

One pharmacist evaluating specialty drug claims using integrated medical and pharmacy claims and PA data can identify enough savings opportunities to achieve a 9:1 ROI

In this study, one managed care pharmacist armed with advance analytics worked through integrated medical and pharmacy benefit claims records. By collaborating with the Blue Plan insurer case management team, the pharmacist was able to optimize drug therapy. This resulted in substantial drug savings.

After reviewing approximately 1,500 member files, 365 were identified as having an actionable opportunity. The pharmacist reviewed the drug therapy regimens of selected high-drug-cost identified members. The regimens were evaluated to ensure appropriate use, identify suspicious utilization, and discover savings opportunities. Advanced analytics combed through millions of member files to zero in on 1,500 members to assess. Of the 365, 20 resulted in validated savings.

Savings opportunities were classified as:

• Changes in drug dosing units
• Therapy changes
• PA approval process changes
• FWA recovery and future claims avoidance

While 20 may sound like a small number, the high-value opportunities and PA process changes added up quickly, to a total of $2.7 million.

For example, a change to the detailing process to ensure correct number of fills in hepatitis C claims affected 28 members and added up to $1 million in savings. After subtracting salary and administrative costs of $300,000, final savings totaled $2.4 million, giving a return on investment of 9:1. Package size optimization for seven members using secukinumab saved $327,000. All savings were validated by claims or by the health plan. 

Prime calls another win for carve-in pharmacy benefits; it’s just better than carve-out