Stopping a High-Cost Specialty Claim Before it Became a Long-Term Drain

A newly-initiated specialty medication costing more than $20,000 monthly went unnoticed by traditional reporting for an employer until it was identified by the PSG team using our Artemetrx data and analytics platform.

The Challenge

The client usually reviewed high-cost claims through traditional PBM reporting methods, raising questions months after issues appeared. Historically, once the PBM confirmed utilization management edits were in place, the review process stopped there. Deeper clinical or formulary validation did not typically occur.

On behalf of the client, our pharmacy benefit consultants identified a new specialty medication utilization exceeding $20,000 per month. This was done during proactive, routine monthly monitoring using PSG’s proprietary data and analytics platform, Artemetrx. This utilization represented a new claim that had not been present in the prior six months and therefore carried elevated risk. Standard PBM reporting would have lagged, catching this at least a month later or, more likely, it only would have surfaced quarterly or semi-annually.

The core risk was clear. Without early intervention, the plan would continue paying for a high-cost specialty medication until it was uncovered much later by traditional PBM reporting.

PSG’s Supporting Services

Artemetrx: An integrated platform that transforms data into intelligence, driving improved management of drug spend and trend across both the pharmacy and medical benefits.

Clinical Consulting: Our team of experienced pharmacists provides unbiased clinical expertise to help clients make informed decisions that optimize their plans.

Learn More

Outlier claims have the potential to materially impact spend, especially when unnoticed. Download the case study to learn the value of proactive, monthly monitoring paired with clinical review rather than reliance on delayed or traditional reporting alone.