So, you’ve watched your prescription costs rise beyond the consumer price index and surpass other medical cost increases and realize a Pharmacy Benefit Management (PBM) component to your managed care program is the way to go.
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Before choosing a vendor, do your homework and review several programs to compare services. Three important considerations are:
1. Program penetration and what the PBM will do to increase program usage. Your employees have to use the program for it to be effective. Most PBMs mail cards, some provide a letter or card to be handed to an employee at the time of injury designed to cover a first-fill up to a set dollar amount and others offer further personalized service to increase penetration.
2. Ease of use for the adjuster. The more automated the process, the better.
3. Advanced technology and what it can do for you all the way from seamless transactions to management reports. Online access to data with an agile system allowing you to dissect and analyze information will go a long way in helping manage pharmacy costs. You should have the ability to detect high cost claimants and prescribers, be confident employees are given the proper medication in accordance with your formulary and know non-compensable prescriptions will be refused. Be sure to have a conversation with your TPA to inquire about data interface.
4. Run a pilot program for 60-90 days to confirm there will be actual savings as promised in the sales presentation. Savings reports should be based on reductions below any applicable fee schedule and generics should replace brand name drugs whenever possible. Your PBM should produce benchmarking and industry comparisons as well, at your request.
Once you’ve selected a program, your TPA is on board and electronic interface is accomplished, work with the claim staff to be sure processes are in place to notify the PBM of claim denials, settlements or if prescriptions are no longer covered for whatever reason. Establishing a predetermined period the card can be used and allowing the adjuster to extend or limit that period is an effective management tool. Be sure to capture the first fill to maximize savings.
5. Prospective and retrospective components — your program should have both. An example of a prospective component is: formulary, prior authorization programs (clinical team makes recommendation to adjuster or medical advisor who approves). Examples of Retrospective components are: targeted medication review, intervention programs such as in network and out-of-network transactions, risk assessments, prescriber “alerts” about employee going to other doctors and obtaining multiple RX, screening for fraud and abuse and comprehensive medication reviews.
Using a PBM as part of your overall managed care program is an excellent tool to reduce pharmacy costs. Choose the best provider for you and encourage employee participation. Be sure to use the management reports to spot areas for further attention such as the high cost prescribers and monitor your savings! (workersxzcompxzkit)
Author Robert Elliott,executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, health care, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. He can be contacted at: [email protected] or 860-553-6604.
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By: Private investigator with 25 years experience.
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers’ comp issues.
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