A small share of prescriptions can drive a massive share of pharmacy spend.
One percent of prescriptions can drive more than 40% of pharmacy costs, according to our client reports. When spend is that concentrated, a focused strategy can uncover major opportunities without creating unnecessary friction across the whole plan.
For self-funded employers, that changes where the work should happen. Instead of applying the same level of intervention across an entire plan, attention can narrow to the areas creating the greatest exposure while protecting access and continuity for everyone else.
What Does Targeted Pharmacy Spend Management Look Like?
Targeted management starts with reviewing claims data to identify high-cost prescriptions that contribute most to pharmacy spend.
From there, employers can weigh changes that could improve clinical or financial outcomes without broadly changing pharmacy benefits, such as:
- High-cost specialty medications
- Therapies with lower-cost, clinically appropriate alternatives
- Prescriptions with specific approval criteria
Concentrated spend calls for concentrated attention.
Specialty and other high-cost therapies make up a small share of prescriptions but account for an unbalanced share of pharmacy spend, and the growth of newer high-cost treatments is raising that cost further.
Recent pharmacy market developments are creating new opportunities for employers to address that spend more strategically.
A review might confirm whether a high-cost therapy meets established clinical criteria, identify a clinically appropriate alternative, or help a member access the same therapy through a more affordable channel.
For employers and brokers, this is a clear opportunity for intervention.
Clinical Review In Action
When one of our members was prescribed an ultra-high-cost therapy for a rare genetic condition with specific diagnostic requirements, US-Rx started a review immediately.
The member’s clinical history and supporting documentation determined that the established criteria for the therapy were not met. The prescribing physician agreed with the assessment, and another course of treatment was pursued.
Approximately $2.2 million in unnecessary annual plan spend was avoided through a clinical decision backed by evidence.
In another case, the opportunity came down to formulation.
A young member undergoing leukemia treatment had been prescribed a high-cost liquid medication that was also available in a clinically equivalent tablet form. US-Rx Care worked with the family and prescribing physician to confirm the member could safely transition.
The therapy continued while approximately $46,000 in avoidable annual spend was avoided.
Both cases show what targeted intervention can look like in practice. Often, small adjustments in a handful of cases reduce costs without compromising member care.
What Should A Pharmacy Review Process Cover?
A pharmacy strategy review should be able to answer a few basic questions.
- Which therapies are driving the greatest financial exposure?
- Are high-cost claims receiving independent clinical review?
- Can members actually get support when a lower-cost option is appropriate?
- Are pharmacy decisions aligned with the interests of the plan and its members?
Clinical oversight can extend beyond the claim by helping members understand available treatment or pharmacy options before cost or access becomes an issue.
Our analysis across client populations nationwide found that member out-of-pocket costs were more than 30% lower through affordability and support strategies.
For employers, that matters because plan performance and member experience are inseparable, and shortchanging one usually affects the other. We offer educational guides on PBMs for employers to help better inform plan strategies.
Over time, employers can add navigation and affordability strategies based on where claims data shows the greatest opportunities.
In one self-funded employer group, plan-paid pharmacy costs per member fell 58% over two years without changing the underlying benefit design or creating broad member disruption.
Results at that scale come from precision. When pharmacy resources are concentrated on the claims carrying the greatest clinical and financial pressure, such as unoptimized drug selection or redundant benefits, employers can pursue significant savings without interfering with the rest of the member population.
Put Pharmacy Resources Where They Can Have the Greatest Impact
High-cost therapies will continue to put pressure on self-funded plans, especially as specialty and emerging treatments become a larger share of pharmacy spend.
Targeted pharmacy spend management gives employers a way to respond with more intention, pairing clinical oversight with member-conscious support and fiduciary alignment.
See where a more targeted approach could make a difference in your plan.
Schedule a conversation with US-Rx Care.