What is Pharmacy Spend in Workers’ Compensation Claims?
Pharmacy spend refers to the total cost of prescription medication needed by an employee as part of their medical treatment and recovery. One of the fastest growing and highest costs of healthcare spending for employers, insurers, and third-party administrators (TPA’s) is pharmacy costs. High-cost prescriptions like opioids, compounded medications, and specialty drugs often drive higher pharmacy spend.
What is clinical insight and how is it used for Pharmacy Spend?
Clinical insight refers to the application of expert medical knowledge to ensure that prescribed medications are necessary, appropriate and aligned with best practices. Reducing pharmacy spend through clinical insight helps lower claims costs while ensuring patients receive the appropriate, medically necessary treatments and prescriptions. Without proper clinical insight, unnecessary or inappropriate prescriptions can increase claims cost, delay recovery and prolong return-to-work timelines. BICMD offers proactive pharmacy spend management through our clinical reviews and expert guidance. We offer a smarter, clinically-driven solution that prioritizes expert insight over denials, ensuring cost savings and better health outcomes.
What are the hidden costs of pharmacy denials?
Traditional strategies to lower the cost of pharmacy claims often include automatic denials, rigid formularies or blanket prior authorizations. However, these strategies often frustrate patients, delay care, and create friction between the employer, employee and claims administrators. While automatic denials seem to be a quick fix to curb rising pharmacy costs, they actually have an opposite effect. Here are some challenges pharmacy denials can cause:
- Increase in administrative burden on providers and payers
- Delayed proper treatment for patients
- Complications due to delayed treatment
- Higher costs when a worker’s condition worsens
- Member dissatisfaction
- Lost productivity
- Longer return-to-work times
How does BICMD help reduce pharmacy spend through clinical insight?
Best In Class MD (BICMD) offers a more strategic, evidence-based way to manage pharmacy utilization. By connecting payers with our network of the nation’s top 1% medical specialists, BICMD delivers objective medical reviews that help control pharmacy costs without relying on blanket denials. Here’s how our clinical insight program works:
- Independent specialist review: We provide access to board-certified experts who conduct an independent and thorough review of complex or high-cost pharmacy claims. We evaluate medical necessity, clinical appropriateness, and if the prescription is cost-effective.
- Fast turn-around: Our early intervention in the claims process will quickly validate needed prescriptions, suggest alternative treatment options, and recommend more cost-effective therapies before costs escalate.
- Reduce unnecessary high-cost prescriptions: Specialty drugs, compounded medications and off-label prescriptions often drive up pharmacy spending. Our BICMD specialists help identify when such treatments are clinically justified and when they are not. Our experts have a proven track record of helping stakeholders avoid unnecessary, high-cost medications.
- Collaborative decision making: Unlike rigid denial-based models, BICMD promotes collaborative patient-centered decision making. Our process ensures that cost savings align with optimal patient care.
Pharmacy Cost Control That Works Across the Claims Lifecycle:
It’s important to monitor the costs of medication throughout patient treatment to prevent additional claims later. BICMD’s clinical insight helps optimize pharmacy spend with our expert-guided medication management. We can help shorten recovery timelines and lower total claims costs, not just pharmacy expenses. Our approach improves injured worker satisfaction by delivering personalized, effective care without unnecessary treatment and medication delays.
Partner with BICMD for Smarter Pharmacy Spend Reduction:
Reducing pharmacy costs isn’t about saying “no” to care—it’s about saying “yes” to the right care. Our Best-In-Class board-certified medical experts help insurers, employers and TPA’s achieve pharmacy cost savings through our evidence-based clinical insight.
Discover how BICMD transforms pharmacy spend management with medically sound, expert-guided solutions. Contact BICMD today for strategic claims guidance and proven cost-containment strategies.