RxBenefits, RxPharmacy Assurance roll out specialty cost, risk avoidance solutions

The sister companies have expanded their suite of clinical management and stop-loss solutions to help self-funded plans maintain affordable pharmacy benefits.
Sandra Levy
Senior Editor

RxBenefits and its sister company, RxPharmacy Assurance, announced new enhancements to their product portfolio designed to improve health outcomes and reduce specialty drug costs for patients and plans.

RxBenefits has expanded and strengthened its Protect suite of clinical utilization management solutions to ensure the appropriate use of high-cost medications. RxPharmacy Assurance offers new, lower deductible options and an expanded list of covered conditions for its supplemental stop-loss coverage to indemnify plans and their traditional stop-loss carriers against catastrophic specialty drug claims.

Pharmacy is the most widely used healthcare benefit, with specialty medications rapidly accelerating risk and spend. Data from RxBenefits’ book of business shows just three drug classesspecialty anti-inflammatory and dermatology drugs and diabetes medications accounted for 45% of drug spend in 2022, without necessarily improving the quality of care, the two companies said.

[Read more: AAM reacts to Avalere study on generic drug costs]

“The pharmacy benefits landscape is more complex than ever before,” said Wendy Barnes, CEO, of RxBenefits. "With drug manufacturers investing heavily in direct-to-consumer advertising and provider detailing to increase their market share and profits, employee benefits brokers, self-funded employers and healthcare consumers need solutions that ensure they pay only for medications that offer good economic and clinical value. Maintaining a competitive and affordable benefits package is a top priority for chief human resource officers and benefits managers, but without appropriate clinical management and catastrophic claim protection in place, most small-to-medium-sized employers will be unable to achieve that goal much longer. As we face an impending economic downturn, innovative, disruptive and client-aligned pharmacy solutions are needed to change the trajectory."

In 2022, the Protect suite of clinical solutions eliminated wasteful spending via independent clinical expertise, oversight and intervention to deliver average annual plan savings in the 5% to 7% range. Now enhanced to directly address the three drug classes driving disproportionate increases in pharmacy spending, RxBenefits expects its newly enhanced Protect suite of clinical solutions to deliver 7% to 10% annual plan savings, while enhancing the health and safety of patients.

The companies said that the new enhancements include the expansion of the company's proven and highly differentiated pharmacist-led prior authorization process, which encompasses a review of patient chart notes to uniquely address the recent increase in the prescribing of high-cost next-generation diabetes drugs like Ozempic and Mounjaro for weight losssomething that may not be detected by PBMs' electronic PA processes.

[Read more: Avalere analysis examines Medicare Part D’s plan tier placement of generics]

Protect enhancements also include a high-touch therapeutic interchange solution that identifies and promotes lower-cost, effective alternatives in the anti-inflammatory and dermatology drug classes, an enhanced digital engagement platform that offers members real-time access to current prior authorization status and personalized communications, and guaranteed program savings.

RxPharmacy Assurance provides flexible, accessible pharmacy-only supplemental specialty stop-loss coverage with multi-year, laser-free protection from catastrophic specialty claims, above and beyond traditional stop-loss coverage. The new enhancements include a choice of attachment points/deductibles from $100K to $250K, a more extensive list of covered conditions that require specialty therapies and more.

“The Protect and RxPharmacy Assurance solutions are important components of our comprehensive, layered approach to reducing pharmacy cost and risk and improving member outcomes," said Mark Campbell, senior vice president of clinical solutions for RxBenefits. “Our holistic approach addresses the costs and risks of high-cost medications that are impacting employers' pharmacy benefit budgets nationwide. These strengthened solutions help our clients fight back against the rising tide of costly specialty drugs.”

[Read more: RxBenefits unveils Patient Assistance program to lower cost of specialty drugs]

Earlier this year, RxBenefits announced the launch of two new patient assistance solutions, which address key shortcomings of current patient assistance offerings while also alleviating the financial strain for plan sponsors and patients alike. Combining these solutions with Protect and supplemental stop-loss coverage from RxPharmacy Assurance creates a layered approach to help drive plan savings and mitigate risk, with particular focus on high-cost specialty drugs.

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