Key Takeaway: Pharmacy benefit costs often rise when prescriptions move forward without enough clinical review. In this article, Dr. Martty Martinez-Fraticelli explains how duplicate therapies, high-risk interactions, and other drug-related problems can increase both patient risk and plan cost when they are not addressed early. Earlier clinical oversight helps protect patients and reduce unnecessary spend.
As President & CEO of PharmPix, I’ve spent time reflecting on where we began and what continues to shape how we think about pharmacy.
PharmPix was built in Puerto Rico, in a healthcare environment where resources are more constrained, chronic conditions are more prevalent, and the margin for error is smaller. The consequences of getting it wrong are immediate.
You learn quickly that every prescription carries weight. Not just in cost, but in outcomes. In whether a therapy works as intended. In whether a patient improves or experiences complications that could have been avoided.
From the beginning, we were guided by a simple principle: the role of pharmacy is not just to process or dispense medications, but to ensure they are used correctly. That requires more than processing prescriptions. It requires accountability for the decision itself.
Because in that environment, getting it right later isn’t good enough. You have to get it right the first time.
Building a Different Model of Pharmacy Benefit Management
As we’ve expanded into the U.S. market, one thing has become clear. The system is built to move prescriptions efficiently. It’s not always built to challenge whether they should move forward at all.
Decisions happen across multiple points, but accountability is often unclear. Prescriptions are written, processed, and approved as they are, even when they don’t fully align with clinical intent. By the time a problem is identified, the medication has already been dispensed.
At that point, the system is no longer preventing risk. It’s responding to it. That’s where plan costs increase and patient harm is introduced, through routine decisions that are never questioned.
We built PharmPix with a different expectation: that every prescription should be evaluated before it moves forward. That clinical oversight should exist at the moment a decision is made, not after the fact.
Because that moment is where pharmacy either protects the patient and the plan, or it doesn’t.
What We See When We Look More Closely
That difference becomes clearer when you look at what is actually happening across prescriptions.
We analyzed six months of claims across a subset of our book of business, focusing on prescriptions where drug-related problems were identified and addressed as they moved through the system.
What we found wasn’t a series of isolated issues. It was a pattern.
Across drug categories and clinical scenarios, the same types of problems appeared consistently. Many were preventable. Most would have continued forward under a model built to process, not evaluate.
Over that period, addressing those issues resulted in more than $2.2 million in estimated pharmacy cost avoidance, or approximately $2.00 per member per month.
These were not projections. They were real prescribing scenarios where therapy was adjusted before it led to larger clinical or financial consequences.
We identified high-cost duplications such as:
- Skyrizi with Hadlima or Taltz
- Ozempic with other GLP-1 agonists, DPP-4 inhibitors, or duplicate dosing
- Cabenuva with Biktarvy or Juluca
- Lenvima with overlapping doses
- Darzalex with other multiple myeloma therapies
- Humira with biosimilars
- Mirena with other contraceptive therapies
These situations often stem from transitions in care, multiple prescribers, or limited visibility into a patient’s full medication profile. Left unaddressed, they drive unnecessary cost and increase clinical risk.
A second pattern emerged around high-risk drug interactions, many of which would not have been flagged before the medication was dispensed. These are combinations that can reduce efficacy, increase toxicity, or create avoidable complications. When they move forward unchecked, the impact doesn’t stop at the prescription. It often leads to additional treatment, emergency care, or therapy failure.
For the patient, that introduces unnecessary risk. For the plan, it drives costs that are far more difficult to manage once they occur.
We protected against high-risk interactions such as:
- Xarelto with Clopidogrel, Aspirin, or Verapamil
- Paxlovid with Statins, Verzenio, Birth Control, or Xarelto
- Keytruda and Opdivo with Dexamethasone, PPIs, or Opioids
- Calquence with Famotidine
- Talzenna with Xtandi
In each case, the difference was not just identifying the issue. It was protection before the therapy reached the patient, because every prescription carries more than cost. It carries consequence.
Why Clinical Decision Making Matters in Pharmacy
The most important pharmacy decisions aren’t financial. They’re clinical. And when those decisions are wrong, the consequences aren’t just budgetary. They affect real people
.
PharmPix began 17 years ago with that belief. Founder-level pharmacist involvement shaped the model from day one—grounded in clinical appropriateness, safety, and accountability long before “transparency” became a marketing term.
It came from what we saw early on. You don’t always have the luxury of getting those decisions right later. You have to get them right when they are made.
That perspective continues to shape how we build and how we partner. To our clients and partners, thank you for trusting us to take on that responsibility with you. We don’t take that lightly.
FAQs
How does inadequate clinical review increase pharmacy benefit costs?
When duplicate therapies, unsafe interactions or inappropriate treatment combinations move forward without review, they can lead to additional treatment, avoidable complications and higher medical and pharmacy spending.
What drug-related problems can a PBM identify before a medication is dispensed?
A clinically focused PBM can identify potential duplicate therapies, drug-drug interactions, dosing issues and treatment combinations that may not align with clinical intent.
What is point-of-sale protection in pharmacy benefit management?
Point-of-sale protection is the clinical review that occurs while a prescription is being evaluated, before it is dispensed. It creates an opportunity to assess, question or correct a potential problem before it affects the member or plan.
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