Prescription for Savings: Smarter Pharmacy Spend Strategies

In this episode of MEC Connect Impact Stories, Dana Dorsey, RN, BSN, CCM, MSCC Medical Management Consultant at MEC, takes a closer look at one of the most overlooked drivers of claim costs: pharmacy spend. What appears routine on the surface—the same prescription, dosage, and outcome—can carry vastly different costs depending on how and where it’s dispensed.

Through two real-world cases from the fire service, Dana explains to listeners how MEC’s people-first, outcome-driven approach uncovers savings without disrupting care. From optimizing pharmacy benefit manager (PBM) strategies to evaluating retail versus mail order fulfillment, you’ll hear how small, strategic decisions can deliver meaningful financial impact.

The episode also explores the transition to a biosimilar for a complex sarcoidosis case, highlighting the importance of collaboration across claims teams, prescribers, and PBMs to ensure seamless care and cost efficiency.

These Impact Stories underscore the way MEC’s powerful combination of expert people, proven processes, and data-driven insights lead to better recovery outcomes and measurable savings—helping clients achieve smarter, more sustainable results.

Transcript

Welcome And Pharmacy Spend Focus

SPEAKER_01 0:02

Welcome to MEC Connect Impact Stories from Midwest Employers Casualty. I'm Sarah Hans. This season, our medical management consultants are sharing impact stories, real-world cases that demonstrate how strategic decision making, oversight, and collaboration can make a meaningful difference in complex claims. Today, Dana Dorsey joins us to discuss smarter pharmacy spend strategies. Let's dive in.

Case One Prostate Cancer Treatment Costs

SPEAKER_00 0:31

Exploring alternative pharmacy benefit managers or PBMs and medication dispensing methods such as retail pharmacy versus mail order can result in a significant cost savings. I would like to present two presumptive cases to demonstrate this. A presumptive condition is assumed to be work-related based on the nature of the injured worker's job and exposure to specific hazards. The first case involves a 51-year-old firefighter who was diagnosed with a prostate cancer in 2015 at the age of 41. Unfortunately, the cancer metastasized to his lymph nodes and bone. He underwent surgery, eradical prostastectomy, followed by stereotactic radiotherapy. The claimant was started on Elagard injections, a hormone therapy used to decrease hormones that make prostate cancer worse. The Elagard injections were given in the provider's office every four months, and in addition to this, the claimant takes aberterone, also a hormone therapy, and prednisone. The injured worker continues to do very well and remains active, including working for the insured.

Price Check Retail Versus Mail Order

SPEAKER_00 1:39

The MEC team identified Elagard and Aberaterone as the cost drivers of the claim. We engaged our preferred PBM and obtained a cost comparison to see if the Elagard and the Aberadorone could be obtained at a more cost-effective fee. The results didn't reveal any savings pertaining to the Elagard. However, there was a significant cost savings of $6,408 or 65.8% at a retail pharmacy or $9,482 or 97.3% savings via mail order for the Aberadorone. The MEC team arranged a conference call with the TPA Claims Adjuster and discussed the potential cost savings. The claims adjuster was on board with our recommendation to switch the Aberadorone to mail order via our preferred PBM and agreed to discuss the potential change with the claimant. The MEC team continued to follow up with the TPA claims adjuster to address both hers and the claimant's concerns and questions.

Preventing Gaps During The Switch

SPEAKER_00 2:40

We also provided details such as the following to assist with the process and to ensure there would be no gaps in the claimant's treating. The claimant would need to have a two-week supply of medication on hand while transitioning to the mail order program. He would need to fill out the mail order form provided by the PBM. The mail order pharmacy would reach out to the prescriber for the prescription. Mail order would not automatically provide a 90-day supply of medication. The prescriber would need to write a prescription for the 90-day supply. And in order to prevent stockpiling, the claimant would need to request refills, which could be done via phone, email, or text via the mail order pharmacy's patient app. Fortunately, the claimant agreed to change to our preferred PBM and to receive his Aberitorong via mail order, resulting in an annual cost savings of $113,795.

Case Two Sarcoidosis And Complex Care

SPEAKER_00 3:34

The second case involves a 55-year-old male fire captain who was diagnosed by lymph node biopsy with sarcadosis. Sarcidosis is a chronic inflammatory disease characterized by the formation of small non-cancerous lumps called granulomas in various organs of the body. He was diagnosed in 2004 at the age of 35. The sarcadosis affected the claimant's pulmonary system with hypoxia, especially at higher altitudes, his heart with a first-degree AV block, and he experienced neuropsarcadosis manifestations with significant symptomatic peripheral neuropathy in both of his legs up to his knees, soycard artropathy in both hands, and hip and foot pain. The claim was amended to include bilateral foot neuropathy and pulmonary hypotension caused by the sarcadosis. On June 29, 2005, the claim closed due to the claimant achieving remission. However, the sarcadosis became very active again involving pulmonary symptoms, and the claim was reopened in January 2011. The claimant retired in January of 2013. He initially treated with an immunosuppressant called methotrexate and then transitioned to Cell Sept in 2013, followed by Humera in 2015. However, the methotrexate and humera were discontinued in December of 2018 due to a skin reaction. Basal cell carcinoma was added to the claim, and due to an increase in his symptoms, the claimant was restarted on Humera in 2021. He continues to treat with a pulmonologist, neurologist, rheumatologist, dermatologist, and optometrist with office visits, labs, diagnostics, studies, and medications.

Moving From Humira To Biosimilar

SPEAKER_00 5:25

The MEC team identified the Humera as the major cost driver and in July of 2023 discovered that a biosimilar generic had recently become available. However, the claimant had not filled the medication since February of 2023. He resumed filling Himera in November of 2023 and in February of 2024, the MEC team confirmed with our preferred PBM that Himera had two interchangeable biosimilars that could be utilized. We agreed that the claim would be a good candidate to refer to our preferred PBM for assistance with notifying the prescriber and transitioning the claimant to the biosembler. Approval to proceed was obtained by the TPA Claims Adjuster and a referral was submitted. Our preferred PBM reached out to the prescribing physician who agreed with the change to the Biosimilar HIROMIS and provided a prescription. The claimant began filling the Biosimbler on May 3rd, 2024 at the cost of $1,372 for cost savings of $5,836 a month or $70,035 a year.

Key Takeaways And Follow The Show

SPEAKER_00 6:32

So these are two examples of how the MEC team made a difference by simply mitigating prescription costs.

SPEAKER_01 6:42

We hope today's impact story offered valuable insight into how thoughtful medical management can influence recovery, return to function, and long-term outcomes for injured workers. Be sure to follow MEC Connect for more impact stories throughout the season. Thanks for listening.