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Auditing Prescriptions and Medication Claims Can Save Your Plan Money

One of Premier’s Pharmacy Management Unit initiatives is auditing not only prescriptions filled through the pharmacy benefit but also medication claims billed through the medical plan to ensure that patients are prescribed medications that are both necessary and appropriate for their diagnoses. The team also looks for irregularities in the cost of medications to ensure truth in billing.

Recently, with our in-house data warehouse and analytics tool, PremierLinxSM, the Pharmacy Management Team has had great success in assisting our clients in avoiding unnecessary pharmacy spend.  For example, a routine review of pharmacy claims for a client identified a very costly claim for the drug Rayos, an extended-release form of the common medication Prednisone. The medication was costing the client’s plan approximately $23,000 every 25 days. However, treatment with immediate-release Prednisone would have cost the client’s plan about $50 for the same time period. The Premier Pharmacy Management Unit reached out to the Pharmacy Benefit Manager/Claims Administrator to confirm that the patient had satisfied the requirements of a prior authorization before this medication was approved. The question still remained – why was the Pharmacy Benefit Manager approving such an expensive medication that offered no additional clinical benefit over a lower cost, therapeutically equivalent alternative? Furthermore, Premier’s on-site Clinical Pharmacist cited possible safety concerns over long term therapy coupled with the extremely high dosage of Rayos being prescribed to this patient. The Pharmacy Benefit Manager/Claims Administrator contacted the physician to receive clarification about why the more expensive form of the drug was being prescribed.  However, the physician did not offer a medically necessary reason for prescribing Rayos over Prednisone. With both cost containment and patient safety in mind, the physician elected to wean the patient off of Rayos, and other treatment options were explored. Not only did this intervention save the employer money, but also it had a positive impact on both short and long-term care of the patient.

Premier’s Pharmacy Management Unit is a key component in helping self-funded employers manage their health benefits plans. Identifying savings opportunities with PremierLinxSM data analytics and reporting on pharmacy claims paid under both medical and pharmacy plans is a key differentiator in Premier’s ability to do a deeper dive into claims information and ensure successful pharmacy outcomes.

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Amherst, NY 14228

716.688.5600

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