A member experienced a mental health episode and was taken by ambulance to their local hospital. The Emry team conducted a thorough bill review, determining that the hospital processed an internal
Member Cost Avoidance: Rx Prior Authorization
A member required medication for managing their Type 2 Diabetes Mellitus, and their physician prescribed Saxenda. Saxenda was not covered by the insurance plan due to its classification as a weight loss drug, resulting in a high monthly cost of $1,230, which the member could not afford.
Saxenda contains the same active ingredients as Victoza, an FDA-approved drug for the treatment of Type 2 Diabetes Mellitus. After verifying the patient’s diagnosis, Emry liaised with the PBM to obtain necessary prior authorization criteria for Victoza and worked with the prescribing physician to initiate the prior authorization process.
With the successful prior authorization process, the member was switched to Victoza, the right drug for managing diabetes, at a cost of $0 per month – an annual savings up to $14,760.
Rx Prior Authorization
Suggested Case Studies
A member visited the emergency room and required a CT scan and other major medical tests. Following their visit, they were faced with two significant bills, totaling over $38,000.
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