Analyzing Claims Data Leads to Millions in Savings

Case Study


PEPM Rx cost took a huge jump in September of 2015, and after a few months, it was clear that this was not an aberration, but the new “normal”. The spike was so profound that year over year Rx costs more than doubled - to the tune of an additional $2.8M dollars. The claims revealed that one drug, being used by three members of one family, was accounting for the entirety of the additional spend.


Identification of the extremely high-cost medication led our team to discover different potential treatment options, different avenues of procuring the medication, and different programs offered by the manufacturer to offset the cost. One of the more attractive options to the client was to exclude the high-cost medication in favor of a much less expensive alternative that was discovered by the data team. However, before doing so, we brought in an array of clinical expertise to make sure that there would not be any potential negative impacts to the members.


This strategy was implemented at renewal (1/1/17) with the immediate impact of driving Rx spend down to the lowest levels in three years. Projected savings (claims only) is ~$2.6M. Not only did the family members see a tremendous reduction in costs, they ended up seeing improved health overall in other factors by switching medications. A year later, they were all off medications entirely.

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