Specialty drug costs represent a disproportionately large share of prescription drug spend and employer-sponsored health plans face potentially devastating consequences as those costs continue to climb.
In January 2018, Pareto retained the services of a clinical pharmacist to perform a second level of clinical prior authorizations for all specialty medications already approved by the PBM for members of the Pareto Rx Consortium (“PRxC”).
In the first two months alone, that extra effort and attention yielded impressive results. “We expected the extra step would generate savings,” said Andrew Cavenagh, Managing Director of Pareto Captive Services, “but the extent of savings is just staggering.”
Of the 71 specialty scripts reviewed, the Pareto clinical pharmacist denied 17 scripts for reasons such as the diagnosis failing to match the dosage, unauthorized off-label use, non-compliance with FDA guidelines, and failure to first attempt less invasive treatment (step therapy). In total, this process saved nearly $700,000 for the captive and its Members.
“The more we dig into specialty drugs, the more obvious it is that extra effort and attention – which is the antithesis of the industry’s typical auto-adjudication process – really can lead to savings for Members,” said Cavenagh.
In one case, a patient was prescribed Korlym, a medication that controls high blood sugar in adults with Type II Diabetes or glucose intolerance that have failed surgery or are not surgical candidates. Upon reviewing the medical records, the clinical pharmacist discovered the patient did not have the proper testing required to verify the diagnosis. This drug would have cost the plan $168,000 per year, and it would have subjected the patient to potentially dangerous side effects while offering little or no therapeutic value.
In another instance, a patient with rheumatoid arthritis patient requested a renewal of Humira. On the form for prior authorization, the nurse indicated the patient is not experiencing side effects related to the medication, and their symptoms were improving, but a review of the chart notes showed a much different story. In fact, the patient was experiencing problems related to musculoskeletal, hematologic, neurologic, and other toxicities prompting the physician to suggest a change in medication was warranted. The Humira was denied, sparing the patient ongoing adverse effects and saving the plan $72,000 a year.
Cavenagh noted these examples highlight another important benefit of the clinical authorizations. “Remember the benefits are not only financial; instead, these denials represent improperly prescribed medications – which can have dire consequences to patients. By insisting on adherence to FDA guidelines, or implementing a step therapy program, you protect patient outcomes, too.”