At Meritain Health Pharmacy Solutions (MPS), our CARE team works tirelessly on behalf of our pharmacy members and customers. Recently, a CARE specialist was able to save an employer and a patient a tremendous amount of money by doing what they always do—going the extra mile.
Evaluating care settings for savings opportunities
Following an inquiry, our experienced clinician was asked to compare a prescription typically used for rheumatoid arthritis with available biosimilars. This was in response to an employer who had identified high-dollar utilization. After review, it was discovered a patient was receiving infusions at an outpatient hospital facility. These generally have higher associated costs than other sites of care, such as in-office or home infusions. In fact, the plan’s medication cost per infusion neared $70,000.
Next, an analysis was conducted to evaluate the cost differential between the pharmacy and medical benefit. The clinician also reviewed the cost differential with available biosimilars. The result? The cost of the brand-name drug was significantly reduced under the pharmacy benefit. Through a copay program, the estimated cost to the plan per infusion through would be less than $10,000 with a 30 percent copay. Utilizing the available formulary biosimilar had an even greater cost saving opportunity, around just $4,000.
Coordinating efforts with the patient’s provider
Based on the identified savings opportunity, our CARE clinician reached out to the patient’s provider to discuss the potential of switching from the medical to the pharmacy benefit. She explained switching would be more cost-effective for the patient, would reduce the total cost of care and would not disrupt the patient’s therapy. After a few initial hesitations, the provider agreed to the proposed benefit change, although declined on switching to the biosimilar alternative.
Our clinician next coordinated with the provider to set up shipment from CVS Specialty® pharmacy in time for the patient’s next scheduled infusion. This provider submitted a new prescription for a generic version of the patient’s medication to CVS Health®. This resulted in an even greater cost savings for the employer and patient.
Ensuring great end results
Finally, our clinician outreached the patient to advise them about the benefit switch. They were also able to assist the member with enrolling in copay assistance. After enrolling, the patient’s copay was brought down to zero dollars. The patient’s reaction? They were overjoyed and totally surprised. Before this, they had no idea programs like this were available to help save money on their specialty prescriptions. And the final result for the employer? They couldn’t have been happier with a new estimated annualized savings of approximately $700,000.
Once again, our MPS and CARE team advocates exemplify how they can save employers and patients money, while advocating for better health outcomes.
This story is based on an actual member experience. Names and information have been changed to protect member privacy.
This communication is intended for informational, promotional purposes only. The reference to previous outcomes made as a part of this communication does not guarantee success or similar outcomes in any new or future cases, as the result of each case depends upon many factors, including but not limited to the facts of each case. Any actual savings will vary based upon numerous factors, and neither Meritain nor its affiliates guarantee any level of savings.
