A contractual issue with the previous vendor required PharmPix to implement their pharmacy benefits over a weekend. Accurate and complete eligibility data was lacking.
How We Fixed It
PharmPix worked with the eligibility data that was available and built a customized eligibility tool, made an eligibility call center available with access to the eligibility tool to correct inaccurate eligibility data, and came up with a communication strategy with providers to make them aware of the sudden change of PBM. We effectively used our Power Copy tool and enhanced their platform capabilities.
End Result
Our client was very happy with their new accurate benefit design and formulary management. PharmPix successfully transitioned all of its members in just one and a half weeks.
The plan was suffering elevated pharmacy costs of $149.85 PMPM (Per Member Per Month) in 2010. It needed a costs turnaround in order to survive in a Medicare-regulated environment.
How We Fixed It
PROSSAM Plus transitioned into PharmPix’s full PBM services effective January 1, 2011. PharmPix then managed the client's pharmacy benefits for the following 10 months, decreasing their pharmacy costs to $119.12 PMPM. This represented a reduction of $30.73 PMPM or 20.6% from 2010. From this reduction, $7.68 PMPM, or 25%, was due to pricing reductions.
End Result
Utilization reduction represented 75% savings within less than a year, or $23.05 PMPM. Our client survived and thrived in their Medicare-regulated environment.
This client, the local universal worker’s compensation organization in Puerto Rico, identified the need for a front-end pharmacy system for its 20 internal pharmacies that would provide adequate dispensation and inventory records and controls, and a PBM component to deploy clinical, quality, and utilization management tools. The project’s specifications called for a very high level of customization, way beyond the normal pharmacy benefits administration.
How We Built It
Eligibility
Handling and/or generating ad-hoc, incident-based eligibility at the point of service
Consolidating multiple cases into a single patient record
Centralizing all patient information received from different pharmacies and other internal and external systems and providers to maintain an up-to-date patient profile
Providing for various patient identifiers including case number, patient name and address, date of birth, SSN, as available to avoid patient identification mistakes
Integration
Fully integrating the front-end pharmacy system with the PBM to create a seamless environment
Including hospital inpatient pharmacy dispensation, including IV fluids and solutions into the full cycle, from pharmacy front-end through the PBM approval processes
Integrating inpatient and outpatient drug history
Integrating all existing provider/prescriber, pharmacist and pharmacy technician records including credentials and expiration dates
Customization
Deploying all tools necessary to manage drug purchases, inventory control, distribution logistic, utilization and fraud, waste and abuse controls
Providing capabilities to coordinate benefits for those claimants with employer-sponsored health plans, avoiding further duplication of drug system capable of keeping only one medication record for the same patient with multiple case numbers as well as one medication record for out-patient and in-patient environments
Front-end pharmacy able to integrate with the PBM eligibility system to be able to adjudicate pharmacy claims as soon as the member is eligible
Only one central network system for all the pharmacies to prevent duplicate member records and duplicity of pharmacy services
The front-end pharmacy system had to be the same for out-patient and in-patient records, thus improving the continuity of pharmacy services when members transition from the hospital to the community allowing for an accurate medication reconciliation between settings
System administers drug purchases, inventory control, distribution logistic, utilization controls and controls fraud, waste and abuse
End Result
Through PharmPix’s PBM services, the client is now able to coordinate pharmacy benefits with the Puerto Rico employers it serves. This successful implementation was completed in just 7 months.
Visual analysis to help plan sponsor understand cost impact
Often PBM proposals are evaluated based on their ability to contract brand discounts and manufacturer rebates. Most experienced pharmacy benefit managers realize that generic drugs offer a significant opportunity for savings and rebate strategies, which can conflict with lowest net cost. The fact of the matter is both strategies have merit. Depending on agreement or actuarial data used for full AWPs, both brand and generic and generic substitution rates, the following analysis depicts two times the savings for a 1% increase in generic utilization compared to a 1% discount in branded drugs.
Understanding the math
Total Cost Savings from 1% increase in GDR is twice that of just under 1% increase in brand discount.
