From High Cost to Free of Charge

Rx Advocates

1 Member

Identified for high-cost drug management and alternative sourcing

1 RX

Filled free of charge through a Manufacturer’s Assistance Program

No Disruption

No missed medications, thanks to our Patient Assistant Program

The Situation

One of our clients is a small, self-funded organization with fewer than 30 employees. During the annual plan renewal, their stop loss carrier identified a member who was recently diagnosed with an orphan condition that required a maintenance medication costing $300,000 annually.

Based on this staggering amount, few stop loss carriers were willing to quote their business, and if they did, they provided lasers on the high-cost medication.

With this feedback, the company began to strongly consider returning to a fully insured plan. They decided to meet with their broker and Crumdale Partners to discuss potential solutions.

Crumdale implemented a program that allowed the employer to alternatively source high-cost specialty drugs at substantially reduced costs.

Goals

CLIENT:

The client asked their broker to help find a way to reduce the high costs of the newly identified orphan medication.

BROKER:

The broker worked with Crumdale to develop and implement a specialty Rx cost containment strategy to lower the drug’s costs for the client.

The Results

By proposing a new PBM and stop loss vendor t, we were able to identify an alternative sourcing solution and provide the high-cost medication free of charge to the member and at an 80% discount for the employer.

Pricing

FAVORABLE DISCOUNTS, TERMS, AND CONDITIONS

Stability

DECREASED RENEWAL VOLATILITY

Control

ALLOWS FOR STRATEGIC PLANNING & FINANCING

How We Did It

The client had many issues with their prior pharmacy benefit manager and stop loss carrier, which Crumdale solved by implementing the following:

High-Performing Rx Contract

Experienced Stop Loss Carrier

Patient Assistance Program

Specialty Rx Sourcing Solutions

CRUMDALE’S PHARMACY DIVISION WORKED WITH THE BROKER AND CLIENT TO PROVIDE ALTERNATIVE DRUG SOURCING WITH NO MEDICATION DISRUPTION.

PROCESS

  • Crumdale proposed a new PBM vendor and stop loss vendor.
  • Crumdale identified an alternative sourcing solution to provide the high-cost medication directly to the member free of charge and at an 80% discount for the client.
  • Crumdale implemented a high-performing PBM contract to allow for the alternative sourcing solutions.
  • With the solution in the works, Crumdale assisted the client and their broker in identifying a stop loss carrier that would provide a quote with a conditional laser based on the alternative sourcing.
  • Prior to implementation, Crumdale assisted the member in applying for our Patient Assistance Program, which ensured there was no disruption in receiving their medication.

RESULTS

  • Transformation Rx, Crumdale’s pharmacy division, reviewed the intricate case and identified alternative sourcing solutions for the high-cost member.
  • Once the savings were identified, TRx immediately notified the broker and group to discuss potential solutions.
  • The broker and employer agreed to move forward with next steps and engage the member.
  • TRx’s clinical staff spoke with the member, physician, PBM and drug manufacturer to facilitate the high-cost medication to be filled through a Manufacturer Assistance Program.
  • Once the cost was approved, the member was able to receive the high-cost medication directly from the manufacturer free of charge.