The Facts
- Lives Covered: 1,000+
- Total Drug Spend: $2.2M
- Estimated Variance Discovered: $257,000
- Solutions: truGuard
The Problem: Unintended GLP-1 Claims
A consortium of plans partnered with their benefits consultant and PBM to renew their pharmacy contract, intentionally excluding weight loss GLP-1 drug coverage to their members to help manage costs. The PBM confirmed the plan design and agreed to the GLP-1 exclusions when implementing the new contract.
In the middle of their contract, the consortium implemented truGuard to monitor their claims and ensure their contract was performing according to plan. Once truGuard was implemented, the claims review identified that the contract’s configuration did not align with the negotiated terms, resulting in weight loss GLP-1 claims being covered by the plan.
The unanticipated financial impact was immediately apparent:
- One plan saw over 15% of total drug spend attributed to GLP-1 claims
- Collectively, the plans incurred $257,000 in unanticipated pharmacy spend
The Solution
The plans and their benefits consultant worked with Truveris to investigate the unexpected weight loss GLP-1 claims for which they were billed. Truveris identified that the expected plan design did not match actual claims activity, and that the PBM had programmed their contract incorrectly into their system. Truveris also conducted an analysis to assess which GLP-1 rebates were owed and paid.
With these insights and data, the issue was escalated to the PBM for review, after which the PBM acknowledged and addressed the discrepancy. Future coverage of GLP-1 medications for weight loss was removed from the pharmacy benefits to prevent any new prescriptions, and some members with existing prescriptions to treat weight loss were transitioned to other options.
In this case, structured contract monitoring through truGuard provided critical visibility into an unintended coverage misalignment, allowing the plans, consultant, and PBM to address the issue in a timely manner. Without this level of oversight, cost exposure could have persisted unchecked and would have cost the employers potentially millions of dollars.
The Key Takeaway
Without ongoing pharmacy oversight, contract misalignments may have gone unnoticed, leading to ongoing cost exposure and potential budgetary challenges from GLP-1 claims for the plans. By implementing ongoing monitoring with truGuard, these employers were able to take action to curb further errors, holding their PBM accountable to their contract.
For questions and strategies regarding the impact of GLP-1s on pharmacy spend, contact Truveris today.
Truveris is a leading digital health company focused on delivering truth and clarity in pharmacy. Truveris’ proprietary technology, coupled with deep pharmacy expertise, helps to build a more efficient market that maximizes choice, accessibility, and prescription drug affordability. Our solutions provide the insight and knowledge to help people lead healthier and more productive lives.
