Patient Advocate Success Story: Rx Savings

by | Jun 21, 2017

Home » Blog » Benefits » Prescriptions » Patient Advocate Success Story: Rx Savings

Every day we talk to hundreds of members about a wide variety of issues. One of the issues we constantly help with is medication. Prescription drugs account for about 20% of a company’s total spend, so to address medical costs you have to examine pharmacy spend. With over 7,000 approved drugs in the U.S., it can be complicated for both doctors and patients to know what’s covered by their insurance.

A member recently came to us because they were denied coverage for a prescription. Their doctor prescribed Restasis eye drops to increase tear production. The insurance plan initially said that the member did not meet requirements for prior-authorization (PA) approval. Without permission from the plan, the member’s health insurance would not pay for the service, so she was stuck paying the bill herself.

The member was a new patient at the doctor’s office, and after a thorough examination the doctor determined that Restasis was the appropriate form of treatment. But without PA she would be responsible for over $300 each month for a drug the doctor considered medically necessary. The member would only be responsible for a $50 copay were she to have authorization.

The member clinically satisfied all of the prior authorization requests but one – history of failure or intolerance to at least one over-the counter eye lubricant – and the provider was unwilling to submit an appeal on the member’s behalf. Since this was a new plan for 2017 with a different set of providers, it would have been difficult and time-consuming for the member to challenge the plan herself. The member would have been paying an expensive monthly medication due to a disagreement between the provider and the insurer, and where no generics or alternatives were available.

Prior-authorization approval exists in most insurance plans to minimize costs to the insurer. In a self-funded or coalition health insurance plan, the employer can determine what is covered or not. In this case, HealthJoy worked with the plan administrator to earn an exception for the member. The employer made the final decision on granting coverage adjustments, and our member can now afford her prescription at the $50 copay per month. 

Our Concierge staff spent considerable time working with all parties to make sure the member was taken care of and received the required medication in a cost-effective manner. Helping both employers and employees save money on Rx is one of our core missions. Our medical team has actually spent considerable time in the development of our proprietary algorithm to identify lower cost alternatives. Our prescription algorithm takes into account the following data to identify the best options:

  • Therapeutic alternatives – Doctors prescribe drugs without understanding a patient’s drug formularies. Our doctors can recommend alternatives that are as effective and deliver huge savings
  • Manufacturer coupons
  • Prescription assistance programs
  • HealthJoy’s Rx savings program
  • Mail-order via PillPack
  • International Mail-Order for certain high tier drugs
  • Pharmacy optimization
  • Dosage optimization
  • Generic alternatives

In this case, we were able to deliver savings by just picking up the phone and speaking to everyone. With all of our cost-saving options, we are able to save an average of $65 per month per medication for our members that submit a long-term medication for review.

Related Posts

Where to Start Looking for Prescription Savings

Where to Start Looking for Prescription Savings

It's important that we understand what our medications are costing us—and how to find prescription savings to get the best price.
Most expensive drugs in the US for employers

Most expensive drugs in the US for employers

In a previous blog post, we investigated why drug costs are rising, and what employers and patients can do about ...
Why Drug Costs Are Rising, and What to Do About It

Why Drug Costs Are Rising, and What to Do About It

Drug costs are out of control, and one culprit has recently been placed in the hot seat: prescription drugs. Yearly
[gravityforms id=12]
<script type="text/javascript">if(!gform){document.addEventListener("gform_main_scripts_loaded",function(){gform.scriptsLoaded=!0}),window.addEventListener("DOMContentLoaded",function(){gform.domLoaded=!0});var gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener("DOMContentLoaded",o):document.addEventListener("gform_main_scripts_loaded",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook("action",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook("filter",o,n,r,t)},doAction:function(o){gform.doHook("action",o,arguments)},applyFilters:function(o){return gform.doHook("filter",o,arguments)},removeAction:function(o,n){gform.removeHook("action",o,n)},removeFilter:function(o,n,r){gform.removeHook("filter",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+"_"+e.length),null==t&&(t=10),gform.hooks[o][n].push({tag:i,callable:r,priority:t})},doHook:function(o,n,r){if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[o][n]){var t,i=gform.hooks[o][n];i.sort(function(o,n){return o.priority-n.priority});for(var e=0;e<i.length;e++)"function"!=typeof(t=i[e].callable)&&(t=window[t]),"action"==o?t.apply(null,r):r[0]=t.apply(null,r)}if("filter"==o)return r[0]},removeHook:function(o,n,r,t){if(null!=gform.hooks[o][n])for(var i=gform.hooks[o][n],e=i.length-1;0<=e;e--)null!=t&&t!=i[e].tag||null!=r&&r!=i[e].priority||i.splice(e,1)}}}</script> <div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_12' > <div class='gform_heading'> <h3 class="gform_title">2021 HealthJoy Employee Benefits Insights eBook</h3> <span class='gform_description'>Testing form</span> </div><form method='post' enctype='multipart/form-data' id='gform_12' action='/blog/benefits/prescriptions/patient-advocate-success/' > <div class='gform_body gform-body'><ul id='gform_fields_12' class='gform_fields top_label form_sublabel_below description_below'><li id="field_12_8" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_12_8' >First Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_12_8' type='text' value='' class='large' placeholder='First Name' aria-required="true" aria-invalid="false" /> </div></li><li id="field_12_9" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_12_9' >Last Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_12_9' type='text' value='' class='large' placeholder='Last Name' aria-required="true" aria-invalid="false" /> </div></li><li id="field_12_4" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_12_4' >Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_4' id='input_12_4' type='text' value='' class='large' placeholder='Email' aria-required="true" aria-invalid="false" /> </div></li><li id="field_12_5" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_12_5' >company name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_12_5' type='text' value='' class='large' placeholder='Company name' aria-required="true" aria-invalid="false" /> </div></li><li id="field_12_6" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_12_6' >Company Size<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_12_6' class='large gfield_select' aria-required="true" aria-invalid="false" ><option value='' selected='selected' class='gf_placeholder'>Company Size</option><option value='1-100' >1-100</option><option value='100-500' >100-500</option><option value='500-3000' >500-3000</option><option value='3000-1000' >3000-1000</option><option value='10000+' >10000+</option></select></div></li><li id="field_12_7" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_12_7' >Which Best Describes You?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_12_7' class='large gfield_select' aria-required="true" aria-invalid="false" ><option value='' selected='selected' class='gf_placeholder'>Which Best Describes You?</option><option value='Employer' >Employer</option><option value='Benefit Consultant' >Benefit Consultant</option><option value='TPA' >TPA</option><option value='PEO' >PEO</option><option value='Other' >Other</option></select></div></li></ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_12' class='gform_button button' value='Get Your eBook' onclick='if(window["gf_submitting_12"]){return false;} window["gf_submitting_12"]=true; ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_12"]){return false;} window["gf_submitting_12"]=true; jQuery("#gform_12").trigger("submit",[true]); }' /> <input type='hidden' class='gform_hidden' name='is_submit_12' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='12' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_12' value='WyJbXSIsImFkODg5MTk3ZmY1MDIyZGVjZjEyNWI2ODk1Y2YyMGZiIl0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_12' id='gform_target_page_number_12' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_12' id='gform_source_page_number_12' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> </form> </div>
[gravityforms id=1]
<div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_1' > <div class='gform_heading'> <h3 class="gform_title">State of the Benefits Survey eBook - 1-Col</h3> <span class='gform_description'>Testing form</span> </div><form method='post' enctype='multipart/form-data' id='gform_1' action='/blog/benefits/prescriptions/patient-advocate-success/' > <div class='gform_body gform-body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><li id="field_1_8" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_1_8' >First Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='large' placeholder='First Name' aria-required="true" aria-invalid="false" /> </div></li><li id="field_1_9" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_1_9' >Last Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='large' placeholder='Last Name' aria-required="true" aria-invalid="false" /> </div></li><li id="field_1_4" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_1_4' >Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_4' id='input_1_4' type='text' value='' class='large' placeholder='Email' aria-required="true" aria-invalid="false" /> </div></li><li id="field_1_5" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_1_5' >company name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='text' value='' class='large' placeholder='Company name' aria-required="true" aria-invalid="false" /> </div></li><li id="field_1_6" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_1_6' >Company Size<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_1_6' class='large gfield_select' aria-required="true" aria-invalid="false" ><option value='' selected='selected' class='gf_placeholder'>Company Size</option><option value='1-100' >1-100</option><option value='100-500' >100-500</option><option value='500-3000' >500-3000</option><option value='3000-1000' >3000-1000</option><option value='10000+' >10000+</option></select></div></li><li id="field_1_7" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_1_7' >Which Best Describes You?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_1_7' class='large gfield_select' aria-required="true" aria-invalid="false" ><option value='' selected='selected' class='gf_placeholder'>Which Best Describes You?</option><option value='Employer' >Employer</option><option value='Benefit Consultant' >Benefit Consultant</option><option value='TPA' >TPA</option><option value='PEO' >PEO</option><option value='Other' >Other</option></select></div></li></ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Get Your eBook' onclick='if(window["gf_submitting_1"]){return false;} window["gf_submitting_1"]=true; ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} window["gf_submitting_1"]=true; jQuery("#gform_1").trigger("submit",[true]); }' /> <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='1' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_1' value='WyJbXSIsImFkODg5MTk3ZmY1MDIyZGVjZjEyNWI2ODk1Y2YyMGZiIl0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> </form> </div>
[gravityforms id=9]
<div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_9' > <div class='gform_heading'> <h3 class="gform_title">10 Benefits Presentation Tips from TED Talks eBook - 2-Col (Pop-up)</h3> <span class='gform_description'></span> </div><form method='post' enctype='multipart/form-data' id='gform_9' action='/blog/benefits/prescriptions/patient-advocate-success/' > <div class='gform_body gform-body'><ul id='gform_fields_9' class='gform_fields top_label form_sublabel_below description_below'><li id="field_9_8" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_9_8' >First Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_9_8' type='text' value='' class='large' placeholder='First Name' aria-required="true" aria-invalid="false" /> </div></li><li id="field_9_9" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_9_9' >Last Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_9_9' type='text' value='' class='medium' placeholder='Last Name' aria-required="true" aria-invalid="false" /> </div></li><li id="field_9_4" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_9_4' >Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_4' id='input_9_4' type='text' value='' class='medium' placeholder='Email' aria-required="true" aria-invalid="false" /> </div></li><li id="field_9_5" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_9_5' >Company name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_9_5' type='text' value='' class='medium' placeholder='Company name' aria-required="true" aria-invalid="false" /> </div></li><li id="field_9_10" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_9_10' >Company Size<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_9_10' class='large gfield_select' aria-required="true" aria-invalid="false" ><option value='' selected='selected' class='gf_placeholder'>Company Size</option><option value='1-100' >1-100</option><option value='100-500' >100-500</option><option value='500-3000' >500-3000</option><option value='3000-1000' >3000-1000</option><option value='10000+' >10000+</option></select></div></li><li id="field_9_7" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" ><label class='gfield_label' for='input_9_7' >What Describes You?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_9_7' class='large gfield_select' aria-required="true" aria-invalid="false" ><option value='' selected='selected' class='gf_placeholder'>What Describes You?</option><option value='Employer' >Employer</option><option value='Benefit Consultant' >Benefit Consultant</option><option value='TPA' >TPA</option><option value='PEO' >PEO</option><option value='Other' >Other</option></select></div></li></ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_9' class='gform_button button' value='Get Your eBook' onclick='if(window["gf_submitting_9"]){return false;} window["gf_submitting_9"]=true; ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_9"]){return false;} window["gf_submitting_9"]=true; jQuery("#gform_9").trigger("submit",[true]); }' /> <input type='hidden' class='gform_hidden' name='is_submit_9' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='9' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_9' value='WyJbXSIsImFkODg5MTk3ZmY1MDIyZGVjZjEyNWI2ODk1Y2YyMGZiIl0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_9' id='gform_target_page_number_9' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_9' id='gform_source_page_number_9' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> </form> </div>