Success Story: Finding Value Through Expert Clinical Evaluation

Success Story: Finding Value Through Expert Clinical Evaluation
June 14, 2022 Sue Riordan
Finding value through expert clinical evaluation

Meritain Health® Pharmacy Solutions (MPS), uses a team approach with informed data analytics to derive clinical solutions that often uncover savings for clients and members.

Recently, the MPS team was successful in proposing plan changes for a client that lowered out-of-pocket costs for a member struggling with diabetes. Additionally, this led to across-the-board savings, increased access, and improved education about diabetes care for all members in the population.

Member struggles with heavy costs

An employee working for Client A has diabetes and regularly needs medical equipment to successfully manage his condition. However, out-of-pocket costs for insulin pumps, a continuous glucose monitor (CGM) and other supplies he needed were more than he could handle. He can’t go without these items—but the added cost was causing him a lot of stress.

MPS stepped in to come up with a solution.

Looking at a plan by the numbers

Believing the right answer could be spotted in the data, MPS got to work digging into reports. They began by looking at Client A’s current plan spending to gain valuable insights.

Next, an MPS pharmacist, teaming up with a service manager and strategic account executive, went deeper into the client’s drug usage and utilization reports, as well as the member’s prescription history. Together, this information painted a larger picture that could be analyzed to highlight areas for potential cost savings opportunities.

Small changes, meaningful impact

After careful review, the team identified areas in Client A’s plan that would benefit from small changes. Specifically, altering how diabetic supplies (such as insulin pumps and CGMs) were covered could increase access for members. It would also allow for better monitoring of symptoms to avoid scary health complications, such as blood sugar levels being too high or too low. In addition, an adjustment was outlined to Client A’s current drug coverage. Together, these changes could lower out-of-pocket costs, protect member health and potentially save members from future medical cost increases.

Working with client management, MPS suggested lowering the member copay to $0 on supplies and prescriptions for diabetes care. The goal would be to improve access, help with peace of mind, protect member health and achieve lasting savings. Implementing these recommendations would help the member who had been struggling with costs now—and all members under the plan, for the future! And, improved member health would lead to more long-term savings for Client A.

Putting it all together

To put this plan in action, MPS held meetings at various levels to achieve buy-in. And in the end, their hard work paid off! Client A saw the value and accepted each proposed recommendation. Access to diabetic resources would now be easier for every member, and available at a $0 copay.

As one final step, MPS wanted to improve member education and also impact clinical outcomes over time. To do this, they created a series of documents with information on diabetes, as well as an outline of available treatment options. This extra step would help members better understand their condition and how to best take care of themselves. It’s also a perfect example of how—as Advocates for Healthier Living—MPS is willing to go the extra mile for clients, members and their families.

This story is based on an actual client experience. Names and information have been changed to protect the client’s privacy.

This communication is intended for informational, promotional purposes only. The amount of total savings represents the savings off out-of-network billed charges that are the product of individual negotiations directly with the provider. The reference to previous outcomes made as a part of this communication does not guarantee success or similar outcomes in any new or future negotiation, as the result of each case depends upon many factors, including but not limited to the facts of each case. 

Health benefits and health insurance plans contain exclusions and limitations; see your plan documents for complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary and are subject to change.