New Specialty High-Dollar Claim Review Program: 10/1/20

Emily Torgerson  •   June 24, 2020

It is no secret that specialty pharmacy spend is growing and makes up the majority of many plans’ total pharmacy spend. With so much money at stake, it is apparent that more oversight of specialty spend from independent clinical experts is needed. This is where National CooperativeRx comes in. As a watchdog for our members, we pride ourselves on protecting your benefit plan and bottom line. Recently, this entails implementing our new specialty high-dollar claim review program to help our members manage these extremely high-cost specialty medications.

As our regular high-dollar claim review program demonstrated remarkable success over the last three years, culminating in not only better options, but also hundreds of fraudulent pharmacies removed from network and millions in savings to members, we decided to offer a version that caters to specialty medications beginning October 1, 2020. As with our non-specialty high-dollar claim review program, the specialty program will be available at no additional cost to our members. The specialty high-dollar claim review program will be more specifically focused on reviewing indication-specific dosing of specialty medications.

Our Cooperative pharmacists will review all specialty claims above $10,000 to identify and resolve issues related to off-label prescribing, appropriate dosing and potential opportunities for trial of a lower-cost alternative. We will also continue our non-specialty high-dollar claim review program, reviewing claims in excess of $1,500.

When asked what the Cooperative hopes to achieve with this new initiative, Erica Guetzlaff, Clinical Services Manager, states, “We will help ensure specialty drugs are used appropriately — for example, at FDA-approved doses and for indications specified in clinical guidelines. Specialty drugs are very expensive, so we want to maximize the value of the therapy.”

National CooperativeRx is conducting a pilot beginning July 1, 2020 for 10 of our member groups and then will offer the program to the rest of our membership effective October 1, 2020.

If your plan wishes to implement the program and has not already done so, or if you have any questions, please contact your National CooperativeRx account manager.