Originally published in PM360 magazine.
ShieldRx from ConnectiveRx is the industry’s first fully integrated, AI-driven pharmacy misuse prevention solution embedded directly into the pharmacy workflow.
It was developed to address growing pressures eroding the effectiveness of manufacturer copay programs and increasing gross-to-net exposure: accumulators and maximizers, an increasingly complex payer landscape, evolving pharmacy behaviors, and the scale of affordability and access investments by manufacturers today.
The convergence of these creates unprecedented opportunities for inappropriate claims.
Of the more than $20 billion spent on copay support each year, an estimated $5 billion is lost to potential misuse. Every dollar stopped before payment is a dollar that goes directly back to a brand’s gross-to-net.
Unlike traditional approaches that review claims only after payment has been made, ShieldRx evaluates every claim in real time before payment occurs. The platform runs AI-driven risk models using pharmacy, patient, prescriber, and historical claims data to identify patterns and behaviors that indicate misuse. Its models are validated using 310 million patient profiles and 1.8 million HCP profiles, including specialty and taxonomy data.
There’s been no change to speed. Most claims are processed in seconds. When a claim requires further review, a resolution center will verify, follow up, and document findings without delaying the pharmacy workflow.
ShieldRx gets smarter as misuse tactics evolve. The platform continuously improves as accumulated experience from tens of thousands of claims feed back into real-time models.
Initial implementations across high-volume brands have demonstrated strong detection performance and direct gross-to-net improvement, helping manufacturers protect affordability investments at scale.
