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.

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