4 No-Cost Clinical Oversights to Transform Your Self-Funded Pharmacy Benefit Plan

Emily Torgerson  •   June 8, 2021

Lowering Costs and Improving Participant Experience

In the constantly evolving pharmacy benefit management (PBM) industry, pharmacy expenses and participants’ expectations continue to rise. To keep up, plan sponsors are looking for serious innovation from their providers. 

At National CooperativeRx, our membership has benefited from our oversight for many years. To continue to meet those growing demands, our team implemented four clinical oversight programs. Each one addresses both costs and participant satisfaction. Interested Cooperative members can opt in at their initial implementation or by coordinating with their account representative.

Clinical Innovation Programs That Offer Better Overall Outcomes

Empowering plan sponsors to provide their participants a lower-impact experience with better health outcomes was the goal from the start. The four programs offered were developed to focus on removing fraud, waste, and abuse from pharmacy benefit spend. They include:

  1. High-Cost Claim Review
  2. Supplemental Formulary Management
  3. Pharmacy Network Oversight  
  4. Advanced Utilization Management

The National CooperativeRx Clinical Team Ensures Efficiency

Our team of dedicated pharmacists drives the success of these pioneering programs. They work tirelessly to do whatever it takes to improve bottom-line costs for plan sponsors and outcomes for participants. 

“One important part of these programs is the quality of the team. You just cannot have anybody doing this work and expect the same result. Our team is caring, passionate, invested, and intelligent. They are persistent in servicing our members and participants,” said Deb Thomsen, vice president of coalition development.

The results of the Clinical Innovation programs are a testimony to this work. National CooperativeRx members saved an estimated $15.6 million in 2020 alone.

Members Receive Pharmacy Benefits Without Fees

As a not-for-profit cooperative, we are proud to offer these programs at no cost to members. Other vendors use these programs and marketplace shortcomings to drive revenue. This is another way we are transforming the way pharmacy benefit providers operate. It’s just part of the value of our member-based Cooperative.

“I think it’s important for plan sponsors to know that just because you’re paying a fee for something doesn’t mean that’s a fair value for the return on investment,” Jocelyn Kerl, clinical services manager, said.

Clinical Oversight Plan Details Show the Results


1.  High-Cost Claim Review

The High-Cost Claim Review (HCC) program is a daily examination of new claims over a specific dollar threshold. These reviews are on safety, appropriateness, and potential for lower-cost alternatives. 

The cost threshold is $1,500 for non-specialty medications and $10,000 for specialty. Our team receives an alert once these price points are met and personally contacts patients, pharmacies, and prescribers to educate them on available lower-cost alternatives. 

They take a hands-on approach to maximize outcomes through dose optimization and therapy interchanges. They also review rejected claims and profiles for appropriate billing. While others have similar programs, their per claim fees often whittle away the savings that may occur.

2.  Supplemental Formulary Management

Formularies are a list of medications used to guide participants to the clinically appropriate and lowest-cost treatment options. With the Cooperative’s Supplemental Formulary Management program, we use our clinical expertise to enhance the members’ formulary experience.  We do this by making decisions based on:

  • Surveillance of high-cost/low-value medications
  • Scrutiny of medical foods and devices
  • Stewardship of medical and dental drugs

Our PBM’s standard formulary oversight allows us to expand on and minimize non-essential drug spending that raises plan sponsor and participant costs. Non-essential drug programs like this typically have a fee attached to implement while negotiating this into our contract terms.

“All of the Clinical Innovation programs are tied to market surveillance,” noted Wayne Salverda, senior director of clinical services. “Keeping a pulse on what’s happening and being able to be nimble and respond to what we see in our data is the heart of our programs.”


3.  Pharmacy Network Oversight

The Pharmacy Network Oversight program identifies abusive pharmacies and practitioners. Drivers of low-value medications are then removed from the network. We enroll member groups automatically for their protection. 

The infrastructure we have in place insulates our members from scams and questionable practices, including:

  • Cold call telemarketing from a pharmacy to convince a patient to switch medications
  • Location Discrepancies: When the doctor, patient, and pharmacy are all in different states
  • Unusual claims activity
  • “Red Flag” products

In 2020, we estimate this program saved our Cooperative membership $1.7 million.

4.  Advanced Utilization Management

Our newest Clinical Innovation program launch was Advanced Utilization Management. This program assesses new-to-market or high-cost drug categories. A clinically appropriate plan design update is then made on behalf of the plan and ensures cost-effective drug use. 

We also review drug categories with the potential for inappropriate use. This ongoing system of managing pharmacy benefits results in quicker checks and is just another example of how we are proactive inside our PBM partnership.

One example of the benefit of the Advanced Utilization Management program is for continuous blood glucose monitors (CGM). Dexcom is a CGM medical device that senses blood sugars around the clock through an implanted sensor in the skin. Dexcom has several parts, the transmitters, the sensors, a receiver, and one year of supplies.

Alternatively, plan participants may self-monitor their blood glucose with traditional test strips/lancets and a handheld blood glucose monitor for approximately 83% less cost annually. 

There is no question that CGMs provide clinical advantages. However, implementing the Advanced Utilization Management programs ensures they are used judiciously for type 1 diabetics, children, or those on intensive insulin regimens.

Elevated Quality Care Remains the Main Factor

“So much of the Clinical Innovation work that we are doing is happening in the background,” Erica Guetzlaff, clinical services manager, explains. “While there are certainly direct cost savings and improved member satisfaction, there is so much more work behind the scenes which is contributing to indirect cost savings, patient satisfaction, and most importantly, elevated quality of care.”

What we can measure outside of savings is how many participants have experienced a superior health outcome. And that is where we can state with confidence that these programs are achieving and exceeding their goals.

National CooperativeRx members may enroll in the Clinical Innovation programs by contacting their account representative. New members may opt-in during implementation.