AlignRx provided this employer group with guidance and a creative approach to lower their increasingly high spend due to specialty medications for only a handful of members with a specific hereditary condition. Even though this client had a long-standing relationship with a PBM, they were not proactively addressing their concerns or providing any solutions to help curb their increasing costs. The claims from these specific members were targeted to be lasered and would cost the plan significantly for the coming year. These costs, which totaled more than $150,000 per month, were causing significant financial stress for the employer, who was, at the time, considering staffing cuts to offset their healthcare costs. Through this engagement, AlignRx determined that the PBM was not offering the group aggressive pricing because they hadn’t been up against competitive analysis for some time. In addition, we met with the client to do an initial analysis to determine how they could leverage an outside party to carve out the specialty medications.
Our first goal was to create a fully customized solution to curb the client’s specialty costs. Using the information from the claim file on the specific drug and total dosage, we worked with multiple vendors to design an innovative solution that addressed all of their financial concerns. By bringing in a specialty 3rd-party vendor that uses manufacturer assistance dollars to pay for a significant portion of the required drug, we carved out these drugs from the normal utilization of the PBM. This allowed for valuable savings that may not have otherwise been possible working with the existing PBM.
We then provided additional oversight of the group’s PBM by performing a year-long audit to ensure that they were, in fact, the right partner and that the benefits were configured accurately. Once it was determined that the PBM was the right fit for the group, we were able to help the group renegotiate its current contract to attain considerable savings. The client was able to obtain an increase on their discounts, enhance rebates, and eliminate unfavorable contract exclusions—improving their financial terms and providing savings of 1.8 million dollars.