A claim for Cubicin (generic name daptomycin, an intravenously infused antibiotic), was flagged for review prior to payment because the billed amount of $13,272, was over the group's high-dollar claim review limit.
A Benefit Assessment Form was sent to the prescribing physician, asking for information about the patient's condition and the choice of Cubicin. The physician indicated he was treating a methicillin resistant staphylococcus aureus (MRSA) skin/soft tissue infection (SSTI) with high-dose daptomycin for 28 days.
The Clinical Care Center pharmacist reviewing the claim determined that although the selected agent is in the Infectious Disease Society of America's (IDSA) guidelines for SSTI's the prescribed dose of medication and duration of treatment were outside the IDSA guidelines' recommendations; additionally, even at normal dosing the cost of daptomycin would exceed that of the other recommended agents - vancomycin and linezolid. A request for additional information about the prescriber's rationale for using daptomycin and for the dosing regimen prescribed was faxed to the physician's office.
When the physician's office was unable to provide their rationale, the request for Cubicin was denied. A follow-up conversation between Clinical Care Center Pharmacist and the physician's office resulted in the physician changing the medication ordered to vancomycin. The total cost for vancomycin was $280.
This resulted in a nearly $13,000 savings to the plan, as well as a co-payment reduction for the member!
Back to all Clinical Notes