Client
A county with 568 covered lives on their plan
Challenge
One of the client’s plan members was receiving a dose of Esketamine nasal spray twice a month, amounting to roughly 26 treatments per year. This agent is used for depression that has not responded to traditional treatments. Typically administered via a health care provider, the nasal spray appears on the medical plan and would not be seen on PBM reports. The client was unaware that they were paying roughly $6,000 per dose over an appropriate price.
Solution
Innovative Rx Strategies Medical Surveillance reviews high-cost medications that hit the medical plan instead of the pharmacy plan. Our team of pharmacists identified the overpayment per dose, alongside the likely length of therapy and flagged this as cause for concern. Working in tandem with in-house nurses, case managers on the client’s medical plan and the plan’s account management team, we were able to negotiate improved pricing for the county without disrupting the plan member’s relationship with their provider.
Results
We were able to negotiate the price per dose of nasal spray down from $7,031 to $1099 per dose — a decrease of $5,932 or 84%. Annually, this would save the plan $154,232 on the member’s treatment, which is likely to continue in future plan years.