QALYiQ Program Delivers Significant Savings for Both Members and Health Plans
As part of their treatment plan for hypophosphatasia (HPP), a rare genetic disorder affecting bone and teeth development, one of our members required Strensiq, a medication designed to manage HPP. However, Strensiq’s annual treatment costs ranged from $1 million to $3 million, creating financial challenges for both the member and the plan, one of our key accounts with 3,000 members.
Holistic Cast Management and Financial Support
In response to these challenges, our QALYiQTM program took action. Our team conducted a thorough review of the member’s case to ensure that Strensiq was clinically appropriate for their treatment. Once clinical approval was confirmed, the team focused on addressing the financial aspect of the member’s care.
The Navitus team assisted the member with enrollment in manufacturer copay assistance and grant programs to significantly reduce their out-of-pocket costs for the expensive medication.
A Strensiq dose optimization strategy was also implemented, adjusting the member’s treatment plan to ensure the necessary therapeutic outcome while lowering overall medication costs. By optimizing the dosage, we were able to further reduce the financial impact on both the member and the health plan.
Making High-Cost Treatments Accessible and Sustainable
The proactive, data-driven approach of the QALYiQTM program, saved the plan $190,000 annually through a combination of financial assistance programs and optimized treatment regimens. For the member, this intervention resulted in reduced out-of-pocket costs, while ensuring they continues to receive necessary treatment for their conditions. QALYiQTM is one of the important programs included in the Navitus Key solution.
Compassionate Care and Coordination
A member of one of our key accounts, a legal services organization, was responsible for caregiving and medication management for her husband with cancer. As part of his treatment plan, he was prescribed Revlimid, a specialty drug.
Supporting Patients with Specialty Drug Access
Revlimid is a limited distribution drug with specific dispensing requirements. The couple initially unsuccessfully attempted to fill the prescription at a local retail pharmacy. They faced repeated issues and frustration with the process. The situation became so challenging that the patient considered discontinuing his medication.
In response to their struggles, Navitus took immediate action. Our team worked closely with the couple to provide support. Their client services coordinator empathized with their situation, and worked tirelessly to find different solutions to resolve the situation. Alongside our clinical team, she consulted with the couple to explore alternative retail pharmacists that could fill the prescription more easily.
With the Navitus team’s guidance, the patient’s wife was able to pick up the prescription hassle-free from a new pharmacy, significantly alleviating their stress.
Committed to Exceptional Customer Service and Patient Care
A year later, when that pharmacy stopped carrying Revlimid, Navitus coordinated the transition to another specialty pharmacy, ensuring there was no disruptions in medication delivery. The patient was able to continue his treatment without interruption. His wife was most appreciative and was happy to report that our team’s intervention removed a huge weight off her shoulders.
Pass-Through PBM Partnership Value
Prior to implementing the Navitus Key solution (formerly EpiphanyRx), a mid-size employer in the food industry was grappling with substantial year-over-year increases in per member per month (PMPM) pharmacy costs. The organization struggled to understand their plan’s complexities, particularly around costs and rebates. The confusion made managing expenses difficult.
Optimizing Pharmacy Spend and Enhancing Transparency
To address these issues, the organization’s advisor evaluated multiple progressive pharmacy benefit manager (PBM) offerings. After careful analysis, they selected us as the ideal partner to optimize their pharmacy benefit plan. We provided a tailored approach that focused on enhancing transparency, improving rebates, and implementing effective clinical management strategies.
Partnering with Navitus led to impressive outcomes, including an overall year-over-year reduction in pharmacy plan spend. Notable improvements included a 54% increase in drug rebates, a strong copay assistance program providing $1.4 million in savings to plan members, and a 51% prior authorization approval rate.
After making the switch to Navitus, the client experienced a 47% reduction in net plan cost PMPM ($67.10 PMPM down to $39.50 PMPM) and a 32% reduction in total plan cost PMPM ($76.45 PMPM down to $52.32 PMPM).
The results were clear: Navitus brought much-needed transparency to the pharmacy benefit program, creating significant savings for both the plan and members.
Stay Informed and Connected
Receive expert insights, healthcare tips, and important updates on pharmacy benefits, drug recalls, and more—straight to your inbox.
Examining Trends that Drive Informed Decisions
Now Available: 8th Annual Drug Trend Report
See the latest results and access industry insights you need to navigate current trend drivers.
Related blogs
Navigating Healthcare and Improving Outcomes
Real-world Data Demonstrates Successful Transitions from Humira to Biosimilars
Authors: Justin Arzt, PharmD; Agata Siwak, PharmD, MSBA; Marnie Wickizer, PharmD, AE-C, CDCES; Ryan Schmidt, PharmD; Robert Topp, RN, PhD; Matt Hustad, PharmD All authors are employees of Navitus Health Solutions. Abstract Adalimumab biosimilar adoption…
PBM 101: Why the Model Matters
In the pharmaceutical and healthcare industry, pharmacy benefit managers (PBMs) are conduits of expertise, analytics and savings opportunities, poised to deliver exceptional health care while driving down costs. They coordinate between drug manufacturers,…
Associate Resource Group Spotlight: Green Team
The Green Team believes that small changes lead to significant impact. Whether its reducing waste, conserving energy or implementing eco-friendly initiatives, they serve as an internal hub for expertise regarding environmental sustainability….
PBM 101: The Three PBM Business Models
In the pharmaceutical and healthcare industry, pharmacy benefit managers (PBMs) are regarded by the media as intermediaries between drug manufacturers, pharmacies, health plans and plan sponsors. But they’re so much more than that. PBMs act as conduits…
An Automated Approach to Diagnosis Verification of GLP-1 RA for Type 2 Diabetes Mellitus (T2DM)
This study examines the impact of implementing an automated point-of-sale diagnosis verification system for glucagon-like peptide-1 receptor agonists (GLP-1 RAs) compared to traditional utilization management approaches….
Navitus to Remove Stelara® from Formulary July 1, 2025, Adds Biosimilars to Drive $120 Million in Savings
As the nation’s first 100% transparent, pass-through PBM, we continue to advance medication affordability by prioritizing upfront, real-time savings over rebated models….
Achieving Outstanding Results with Tailored Network Strategies
A medium-sized city in Michigan with 1,350 members was seeking ways to lower its pharmacy benefit costs, which were growing under its existing traditional pharmacy benefit manager (PBM). With its member covered by a two-tier, open formulary including…
Breaking Through Barriers with Value-Based Plan Design
Facing increased pharmacy benefit expenses, Blain’s Farm and Fleet, a Midwestern employer group, desired to improve plan performance. Specifically it was interested in educating eligible members about the benefits available to them, promoting cost-effective…
Finding a Solution to Lower Prescription Drug Costs
The Rural Arizona Group Health Trust (RAGHT) wanted to gain better control of its escalating drug trend with its large, traditional pharmacy benefit manager (PBM). Having only worked with traditional PBMs in the past, RAGHT was interested in exploring…
