Case Study Showcasing How a Clinical Intervention Leads to Appropriate Therapy and Drills Down on Waste in Drug Spend!

Our value-based model takes a closer look at specialty medications to ensure clinical appropriateness for every patient. Interventions such as this drive a client-tailored approach to pharmacy care, resulting in greater financial outcome for the client.

Specialty medications are the biggest driver of plan spend; therefore, our Care Management team reviews each patient case for clinical appropriateness which also helps optimize waste and cost. Our clinical approach is whole-person health: treating the whole patient, not just the condition. During a clinical appropriateness review, an EmpiRx Health Pharmacist examines the patient’s whole health situation and underlying factors such as other conditions and utilization. Armed with precise insights in tandem with evidence-based medical literature, our pharmacists engage the prescriber to discuss the best therapy for members.

Determining the most clinically appropriate and cost-effective therapy for the patient is always the goal, and always the outcome. In this case study, a 52-year-old female diagnosed with Rheumatoid Arthritis (RA) was prescribed Tremfya, an injectable medication previously covered under the client’s medical plan. Our population health engine identified a new specialty medication for this patient in need of a clinical appropriateness review.

A holistic patient view improves clinical recommendations and overall patient health outcomes. Our Clinical Pharmacist reviewed the patient chart notes and identified the presence of other auto-immune/inflammatory conditions, such as Lupus, chronic pain, and osteoarthritis. Chart notes documented poor/unsatisfactory response on Tremfya and that the patient reported Rinvoq had previously helped with symptoms of RA and some of the joint pain associated with the patient’s Lupus. In discussion with the prescriber, it was agreed that Rinvoq would be the appropriate solution to treating the cause of RA and the symptoms of Lupus.

  • The patient’s rheumatoid arthritis was well managed with the new medication recommendation and her quality of daily life improved.
  • Original Prescription: Tremfya 100mg 1 inj/28 days
  • Clinical Recommendation: Rinvoq, 15mg, 30 tabs/30 days
  • Clinical Savings: $40,900

Appropriate clinical and specialty management drives clinically appropriate utilization at the lowest cost to the plan and members. Since the 2021 implementation of the plan:

  • Client experienced 11% decrease in Plan PMPM in their first year under our management, a trend that continues downward in 2022 at -10% YTD. This represents a -19% trend compared to the incumbent
  • The EmpiRx Health population health management strategy was able to achieve $116K in savings within the specialty injectable category
  • +1MM in savings driven by clinical intervention and drug mix optimization


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