From $3,000 to Nearly $0:
How Proactive PBM Advocacy Changed a Member’s Reality
Overview
Following open enrollment, a newly transitioned group moved from a fully insured plan to a new benefit structure. Shortly after, Pharmacy Benefit Dimensions (PBDRx) received a member outreach with a pressing concern regarding a Humira prescription that was now unexpectedly subject to a member copay of over $3,000.
Under their prior plan, an existing authorization allowed either Humira or its biosimilar. The new plan, however, carried a significantly higher cost share for Humira. The member was open to switching to a lower-cost biosimilar option to reduce out-of-pocket expense, but the prescribing physician had written the prescription as DAW 1 (Dispense as Written), prohibiting substitution.
PBDRx’s Approach
Rather than simply explaining the benefit design and financial impact, PBDRx took immediate action:
- Proactive Outreach: Our team promptly coordinated with specialty pharmacy partner, Reliance Rx, to re-engage the prescribing physician and request a new script that would allow the biosimilar conversion.
- Member Engagement: The member was contacted directly, educated on what was needed from the physician, and kept informed of ongoing outreach efforts.
- Savings Opportunity: Reliance Rx conducted additional reviews to identify an avenue to significantly reduce the member’s copay.
- Clear Explanation: PBDRx walked the member through how the claim adjudicated under the new plan, ensuring full transparency and a full understanding of and confidence in the process moving forward.
Results
Immediate Financial Relief
- Member copay reduced from over $3,000 to nearly $0 thanks to the diligence of both PBDRx and Reliance Rx.
Ongoing Clinical Savings
- Member transitioned to a clinically appropriate, lower-cost biosimilar.
- Estimated $2,500 in plan savings per fill.
Trusted Partnership
The member was not only relieved by an alleviated financial burden, they felt supported with continuous, dedicated communication and a high level of advocacy from PBDRx’s team. What began with confusion and concern was promptly remedied, building trust and strengthening the partnership.
Client Overview
Industry: Construction and Materials
Group Size: 100+
Plan Type: Self-Funded Pharmacy Benefit
Big Picture
- This case is just one of many that exemplify PBDRx’s standard of care:
- We actively pursue solutions that prioritize high-quality care at the lowest net cost.
- We advocate for clinically appropriate, cost-effective alternatives.
- We engage providers, pharmacies, and members directly.
- We protect both member affordability and plan sustainability.
Questions
For more information on how you can gain greater control and cost savings on your prescription drug program, call (716) 635-3578 or email PBDSales@pbdrx.com.
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Our 25 years of experience in prescription drug benefit management provides the edge you and your clients need to manage expenses now and in the future.