As an employer, you know the importance of prioritizing your employees’ needs, but you also have to consider your overall clinical and economic goals as the plan sponsor who is paying the cost in order to provide your members with the best possible benefits. Just one unnecessary high-cost drug can put you under on how to provide the best benefits for your employees.
It’s about making sure that all parties are taken care of, and when you do it the right way, the cost will be contained. –Bradley Nelson, PharmD
The Dilemma
This client’s story began with a member who was prescribed Otezla®, a drug often used to treat certain types of psoriasis, which they did not meet the criteria for. After multiple appeals and rejections, the provider prescribed a second drug, Skyrizi®. Skyrizi also treats plaque psoriasis but costs around $70,000 a year – more than double the annual cost of Otezla. The plan was concerned that they were having such a high cost approved, and they wanted to know what the process was and why it got approved.
Continue watching the story to see what our team uncovered after finding that the PBM’s speedy electronic system approved the costly claim and what you can expect with our independent Prior Authorization (PA) review process vs. the PBM’s.
The RxBenefits Difference
With RxBenefits independent PA reviews, there is an actual person following the process. Because of our hands-on approach, you can rest assured knowing your members’ medications are reviewed individually by a team of professionals, not an automated system.
