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PHARMCARE
- PHARMCARE CASE MANAGER PLUS
- PHARMCARE DUR DESCRIPTION
- PHARMCARE INTERNET ACCESS
- PHARMCARE NETWORK PLUS
- PHARMCARE PREFERRED DRUG PROGRAM
- PHARMCARE PRIOR AUTHORIZATION
- PHARMCARE THERAPY MANAGEMENT
PHARMCARE CASE
MANAGER PLUS
Most
medical plan costs are the result of a few large medical cases. PharmCare’s
Case Manager Plus fosters the early identification and management of each
case, assisting in reducing your health plan costs.
In a
real-time environment, PharmCare provides Case Managers specific member information,
including inferred disease state, to assist them in identifying
interventions during the early stages of a disease. We give Case Managers
the power to avoid or more effectively manage high dollar medical claims.
High
cost medical conditions in the program include Cancer, Congestive Heart
Failure, Diabetes, Asthma, HIV/ Aids, and transplants. Other specific
medical conditions may be included as requested by the individual Case
Manager.
The Case
Manager Plus + system is only a click away. You may access detailed reports
including drugs dispensed, date dispensed, drug cost and prescribing
information through direct Internet access to our database. The system is
password protected to ensure the security and integrity of all information.
PHARMCARE CLINICAL PLUS - TARGET
MESSAGING
Pharmacists
can now offer their customers more options and greater cost savings with
PharmCare's Target Messaging. Our Target Messaging System provides
invaluable information and recommendations to the pharmacist before a
medication is dispensed, allowing them to provide the most effective
medications at a substantial cost savings. Pharmacists are apprised of the
latest news and information including:
• Generic Alternatives
• Formulary vs. Non-Formulary Product
Analysis
• Quantity Limitations
• Alternative Dosing Regiments
• FDA Approvals and more
Clearly
explaining key plan specifics supports adherence to cost management
principles of the plan. This information will also enhance the speed in
which prescriptions are filled and encourage member/pharmacist
communication.
The
communication of newly approved generics is an important component in cost
reduction. PharmCare alerts all members as soon as new generic drugs are
available on the market.
Make your
members aware of their options and promote clinically appropriate cost
savings at the point of sale with PharmCare Clinical Plus Target Messaging.
You Make The Choices
PHARMCARE DUR
Description
DUR Settings - The benefit
design dealing with therapeutic duplication, refills, drug-drug interaction
over/under utilization and high dose/low dose checks is displayed through
various flags.
Continue
Profile on DUR Hit - If this flag is marked and the system finds a DUR
error, it will continue to search back through the member’s history for any
other duplication regarding the same type of error.
Refill
Too Soon - When flagged, the system will search through the member’s
history for previous fill of the same medication and the date of that fill.
A rejection will appear if the Hit Disposition is set to reject and the
fill is prior to the RTS D/S Used PCT.
Hit
Disposition - When the associated topic is flagged, the hit disposition
may be set to advise or reject. When set at advise, a warning is sent to
the pharmacy. When set to reject, a rejection is sent to the pharmacy and
may require further action.
RTS
Short D/S Override - RTS Short D/S Override allows the plan to set a
number of days prior to the suggested refill that a prescription may be
filled. The purpose is to override the RTS D/S Used PCT if the day supply
is low. For example, if a member receives a 5-day supply, and the
percentage is set at 75, the member would have to wait until the fourth day
for a refill. However, if the RTS Short D/S Override were set at 3, the
member would be eligible for a refill on day three.
RTS
D/S Used PCT - RTS D/S Used PCT displays the percentage of a fill that a
member must use before they are eligible for a refill. For example, if the
member received a 100-day supply and the RTS D/S Used PCT is set at 60%,
the member may acquire a refill on day 61. The default is set at 75
percent.
Therapeutic
Duplication - When flagged, the system will search through the member’s
history for an overlap of current drugs on the patient’s profile.
Duplications exist when a patient takes two drugs that have similar routes
of administration and similar ingredients that share the same Specific
Therapeutic Class.
TD
Same NABP Check - When flagged, the system will not generate an error if two
conflicting claims are submitted from the same NABP number. The purpose is
to eliminate therapeutic duplication rejections that, with high
probability, the pharmacist has already been made aware.
Check
Type
- Determines the classification (GCN/GCX) that is considered in the
system’s search for therapeutic duplication. Currently, there are four
levels of checks. The first is by GC3. The second is by GCN. The third uses
the list of selected drugs to check for therapeutic duplication when a TD
override list does not exist. If the drug dispensed is in the list of
selected drugs, the system uses GC4 to do check. The fourth level forces by
GC4.
Hit
Disposition - When the associated topic flagged, the hit disposition may
be set to advise or reject. When set at advise, a warning is sent to the
pharmacy. When set at reject, a rejection is sent to the pharmacy and may
require further action.
TD
Short D/S Override - Allows the plan to set a number of days prior to
the suggested refill that a prescription may be filled. The purpose is to
override the TD Short D/S Override if the day supply is low. For example,
if a member receives a 5-day supply, and the percentage is set at 75, the
member would have to wait until the fourth day for a refill. However, if
the RTS Short D/S Override were set a 3, the member would be eligible for a
refill on day three.
TD
Profile Length - When given a value, the value will ignore the absolute
maximum days supply in a profile search. If, for example, the value is set
at 180, the system will look back 180 days into the patient’s history. If
set at 0, the system will default to the absolute maximum days supply.
TD
D/S Used PCT - Displays the percentage of a fill that a member must use
before they are eligible for a refill. The default is set at 75 percent.
Drug-Drug
Interaction - When flagged, a rejection or advisement will be sent to
the submitting pharmacy with notification of Drug-Drug interaction. Drug
interaction codes provided by the First Data Bank are used in the match of
the NDC submitted to the member’s profile.
DD
Same NABP Check - When flagged, the system will not generate an error if
two conflicting claims are submitted from the same NABP number. The purpose
is to eliminate drug-drug interaction rejections that, with high
probability, the pharmacist has already been made aware.
Level
1 Hit Disp - Depending on the severity of the drug-drug interaction
(level 1 being the most severe), the plan may choose to reject or simply
advise.
Level
2 Hit Disp - Depending on the severity of the drug-drug interaction
(level 1-3), the plan may choose to reject or simply advise.
Level
3 Hit Disp - Depending on the severity of the drug-drug interaction
(level 1-3), the plan may choose to reject or simply advise.
DD
Profile Length - When given a value, the value will override the absolute
maximum days supply in a profile search. If, for example, the value is set
at 180, the system will look back 180 days into the patient’s history. If
set at 0, the system will default to the absolute maximum days supply.
Pregnancy
Check - When flagged, the system will advise or reject
medications that warrant a pregnancy alert. Currently, the system advises
rather than rejects all three levels of severity for pregnancy alerts.
Alterations may be made in accordance with plan specifications.
Hit
Disposition - When the associated topic is flagged, the fit disposition
may be set to advise or reject. When set at advise,
a warning is sent to the pharmacy. When set on reject, a rejection is sent
to the pharmacy and may require further action.
PG
Minimum Age - When a variable is displayed in the box provided, the
pregnancy check begins with the age represented by the variable.
PG
Maximum Age - When a variable is displayed in the box provided, the
pregnancy check ends at the end of the age represented by the variable.
High
Dose
- When flagged, the system checks the quantity and the day supply against
the information from the First Data Bank and makes a determination of
dosage. If the dosage is higher than the information provided by FDB, an
advisement or rejection will return to the transmitting pharmacy. The
purpose of the check is to advise or reject doses that fall outside a safe
dosage range. The check enables the pharmacy and the plan to make a
time-efficient judgement without the need of
specific member medical information.
Hit
Disposition - When the associated topic is flagged, the hit disposition
may be set to advise or reject. When set at advise,
a warning is sent to the pharmacy. When set at reject, a rejection is sent
to the pharmacy and may require further action.
HD
PCT Tolerance - Allows flexibility of tolerance by the quantity in the
box provided. For example, a plan may choose to allow a 5% tolerance to the
high dose specifications of First Data Bank.
Low
Dose
- When flagged, the system checks the quantity and the day supply against the
information from the First Data Bank and makes a determination of dosage.
If the dosage is lower than the information provided by FDB, an advisement
or rejection will return to the transmitting pharmacy. The purpose of the
check is to advise or reject doses that fall outside a sale dosage range.
The check enables the pharmacy and the plan to make a time-efficient judgement without the need of specific member medical
information.
Hit
Disposition - When the associated topic is flagged, the hit disposition
may be set to advise or reject. When set at advise,
a warning is sent to the pharmacy. When set at reject, a rejection is sent
to the pharmacy and may require further action.
Over-Utilization - When flagged,
the system searches the member’s history for previous dispensing of drugs
under currently processed drug’s GCN. The days supply and quantity of each
hit is placed into one of two accumulator buckets (either days supply or
quantity) along with the current claim. The total of the quantity
accumulator bucket is divided by the total of the days supply accumulator
bucket and matched against the data from the First Data Bank.
Hit
Disposition - When the associated topic is flagged, the hit disposition
may be set to advise or reject. When set at advise,
a warning is sent to the pharmacy. When set at reject, a rejection is sent
to the pharmacy and may require further action.
ER
PCT Tolerance - Allows flexibility of tolerance by the quantity in the
box provided. For example, a plan may choose to allow a 5% tolerance to the
over-utilization specifications of First Data Bank.
Under-Utilization - When flagged,
the system searches the member’s history for previous dispensing of drugs
under currently processed drug’s GCN. The days supply and quantity of each
hit is placed into one of two accumulator buckets (either days supply or
quantity) along with the current claim. The total of the quantity
accumulator bucket is divided by the total of the days supply accumulator
bucket and matched against the data from the First Data Bank.
LR
Maintenance Only - In searching for under-utilization, this flag allows the
system to bypass acute drugs and adds only maintenance drugs.
LR
Hit Disposition - When the associated topic is flagged, the hit disposition
may be set to advise or reject. When set at advise,
a warning is sent to the pharmacy. When set a reject, a rejection is sent
to the pharmacy and may require further action.
LR
Profile Length - When given a value, the value will override the absolute
maximum days supply in a profile search. If, for example, the value is set
at 180, the system will default to the absolute maximum days supply.
LR
PCT Tolerance - Allows flexibility of tolerance by the quantity in the
box provided. For example, a plan may choose to allow a 5% tolerance to the
under-utilization specifications of First Data Bank.
Duration
of Therapy - This flag is a Maximum Accumulator Type. Age and Quantity
must be met if specified.
Step
Therapy - When flagged, the plan mandates that a lower impact drug
be taken before a high impact drug. The step therapy may contain up to nine
lines or steps of drugs. The first line of drugs must appear in the
patient’s history before the second line of drugs may be filled. A time
frame may be set for the search backwards into the history. For example, if
the time frame is set at 30 days and the member has already received a
first line drug, they may receive a second line drug on the 31st
day. Messages returned to the pharmacy may be set to advise or reject. See PharmCare Prior Authorization Plus for more
information.
You Make The Choices
PHARMCARE
INTERNET ACCESS
PharmCare’s newly designed web site provides instant
access to important information for members, employers & third party
administrators.
Members
Plan members are now just a click away from:
Locating the nearest pharmacy
Reviewing the Preferred Drug Formulary &
Searching for preferred alternatives
Obtaining the latest information about their
particular medication or health question
Reordering or checking the status of their mail
service Rx
Printing forms needed for direct member
reimbursements, updating their member information & obtaining prior
authorization for their specific medication
Employers & Third Party Administrators
Employers have same access as members plus:
Instant access to the latest formulary changes
Ability to download formulary communication materials
specifically designed for members
Access via secure Internet connection to claims &
member information as well as on-line reporting capabilities
All access to prescription data is user and password
protected to insure the integrity and security of patient information.
PharmCare is unique in the
Pharmacy Benefit Management business. We are small enough to insure fast,
accurate, personal service yet we are large enough to provide our clients
with the same range of services as a large PBM. We are able to provide
claims processing which is fast and accurate. Our range of plan design
options includes an infinite number of variables to meet the needs of every
client. Our reporting package provides for a clear understanding of
prescription drug expenses and assists in making cost saving plan changes.
Price discounts are aggressive and meet or exceed any pricing available in
the marketplace today. PharmCare offers a wide
range of clinical services to enhance the quality of care as well as
provide for additional savings. The PharmCare
Plus programs offer assistance with formulary development, case management,
therapy management prior authorization of selected drugs and additional
discounts and therapy management on biotech drugs. We have been in business
since 1986 and have developed a national network of pharmacies that serve
over nine hundred self-insured groups ranging in size from a few hundred to
over twenty five thousand. We constantly search for new ways to serve our
clients and maximize the money they spend on prescription drugs. PharmCare has a proven record of designing prescription
drug plans that insure access to needed medication while insuring
medication is taken appropriately and the most cost effective drugs are
utilized. Please browse our site and contact us if you have comments or wish
additional information on PharmCare.
You Make
The Choices
PHARMCARE NETWORK
PLUS
PharmCare offers two network options to meet the
needs of our clients and their members.
PharmCare Prime Network
Plus+
If you
need superior pharmacy access and maximum available discounts, Prime
Network Plus is your best choice. Members maintain the ability to choose
from an expansive list of pharmacies while plan sponsors may encourage
members to use the most cost-effective providers.
PharmCare Traditional
Network Plus+
This
open access network includes all major chains and most independent
pharmacies, so your employees have more choices as well as a competitive
discount rate structure.
Additional Savings with Mail Service
Enjoy
home delivery and industry leading price discounts through our fully
integrated Mail Service program. PharmCare has
joined forces Express Pharmacy Services (EPS), one of the oldest and
largest providers processing over 8 million prescriptions annually. EPS
provides industry leading dispensing technology through three (3) state-of
the-art mail service facilities.
Members
will have maintenance medications delivered right to their home and can
enjoy the added advantage of ordering refills via direct mail, fax,
internet and toll free 800 lines.
EPS
ensures a pharmacist's initial order review, a simultaneous system review,
and a final pharmacist quality control review to guarantee you and your employees prescription quality and accuracy.
PHARMCARE SPECIALITY PHARMARCY PLUS
The use
of bio-tech and other very expensive "orphan" medications is
increasing as diseases such as Multiple Sclerosis, Hepatitis C., Growth
Deficiencies, RSV, Arthritis and Hemophilia are treated more aggressively.
In order to help control the cost of these types of medications PharmCare offers Specialty Pharmacy Plus. Significant
discounts are offered compared to other delivery systems.
Medications
are delivered to the patient or the patient's physician just before it is
needed for administration. A staff of specially trained nurses and
pharmacists who call the patient prior to shipping each prescription
provides patient care. The patient is questioned to insure that the
medication is being taken as directed, is needed and is producing the
desired results. If problems are identified, the physician is contacted to
insure the best course of therapy.
PHARMCARE DIABETES PLUS
PharmCare has also developed a demand based
management system for persons who have diabetes. Aggressive discounts are
offered along with patient follow-up and calls to determine when additional
medication or supplies are needed. Educations materials are custom designed
for PharmCare and are mailed to patients to
assist them in effectively managing their disease.
A key
component of this program is the regular delivery of an HbA1c to the
patient's home. This test gives the best determination of how well the
patient is managing their blood sugar level. Results are tracked and
monitored for fluctuations in blood sugar levels. Group results are
reviewed with the employer while specific individual results are forwarded
to the patient's personal physician when appropriate.
You Make The Choices
PHARMCARE
PREFERRED DRUG PROGRAM PLUS
The
Preferred Drug Program process is a critical component of pharmacy
management. It has always been PharmCare’s
strategy to develop preferred drug programs without provider or
manufacturer influence.
Our
partnership with WellPoint Pharmacy Management compliments this strategy,
providing the "best" medications for the patient, while balancing
cost consequences for the client.
Preferred Drug Program Selection Criteria
Every 24
months WellPoint conducts a systematic review of all therapeutic classes
contained in the Preferred Drug Program to assure that the most efficacious
and cost effective drugs are represented. These reviews are conducted at
the quarterly Pharmacy and Therapeutics Committee meetings.
PRODUCT EVALUATION CRITERIA:
• Efficacy/Effectiveness (relative to
other therapies)
• Safety (side effects or drug
interactions)
• Pharmacokinetic advantages
(dosing/compliance)
• Product uniqueness vs. clinical
alternatives)
• Cost of therapy
• Outcomes
SELECTION PROCESS:
A
pharmaceutical product must meet at least one of the following criteria to
be included on the PharmCare Prescription Drug
Formulary. In comparison to other formulary products and alternatives, this
product:
• Is more efficacious/effective
• Provides significantly improved side
effect/drug interaction
• Offers more dosing or compliance
advantages
• Is unique and possesses an important
class niche
• Offers a significant cost advantage
(if equal in all other aspects)
• Provides more positive outcomes
Efficacy/Effectiveness (relative to other
therapies)
•
Effectiveness: The drug must he shown to be effective for indications
sought.
•
Clinical Uniqueness: The drug must offer a pharmacological treatment where
none existed previously.
• Clinical Superiority (side effects or drug interactions)
the drug must offer a clinical benefit over other therapies within the
therapeutic class or over other agents used to treat the same disease
state.
• Adverse Drug Reactions/Side effect profile: The agent
under consideration must possess a superior (lower incidence of problems)
or comparable ADIR or SE profile to similar agents currently on the
Preferred Drug Program
• Patient Compliance: The agent must provide a significant
compliance benefit through ease of use of dosed fewer times per day. This
consideration is critically important for geriatric or pediatric
populations.
Cost/Benefit
When a
particular drug in a therapeutic class offers a clinical advantage over
other drugs in its class, it will be added even though it is more expensive
than the other agents. If the drug in consideration is considered equal in
terms of clinical merit, it will be added only if it is less expensive than
the other agents.
TIERED PREFERRED DRUG APPROACH
This
comprehensive Preferred Drug Program option allows for a simplified
determination of preferred versus non-preferred status. All preferred brand
medications are listed in an easy to read alphabetical format increasing
both member and physician acceptance. Generics are always recommended as
first line use where appropriate.
Potential
savings of a three-tier program are 6-12% over standard brand and generic
drug programs.
You Make The Choices
PHARMCARE PRIOR
AUTHORIZATION PLUS
PRIOR AUTHORIZATION
Prior
authorizations require physician documentation of medical necessity and
approval by PharmCare for coverage of specific
drugs. PharmCare has established clinical
guidelines, which must be met before authorization is given.
Prior
authorization forms are available from PharmCare.
These forms must be completed by the physician and sent to PharmCare. Upon review by our clinical personnel,
dispensing of the medication is approved if the physician information is
consistent with our clinical guidelines.
QUANTITY LIMITS
A number
of medications, which often are very expensive or have a potential for
abuse, have been identified. Clinical guidelines for the quantity, which
should be used during a month, have been established. PharmCare’s
automated prescription adjudication system will limit the quantity of these
medications, which can be dispensed each month. Exceptions will be made
only with the approval of the plan sponsor
CONTINGENT THERAPY PROTOCOL
Contingent
Therapy Protocol (Step Therapy) programs allow PharmCare
to administer prescription benefits where on-line reviews of therapy
protocols or treatment guidelines are required to determine if a specific
medication is a covered benefit.
We have
developed these programs to be very flexible for accommodating unique
protocols that our clients have designed. The notification that is sent
back to the pharmacies can be customized to include the specific therapy
guidelines that must be followed, including a client telephone number to
contact for additional information. The following are examples of how these
programs are currently employed:
Appropriate
selection of reserved (second line) therapy.
Clients
identify first line and second line therapies. These products are
maintained in client specific step therapy files. When a prescription is
presented, the member profile is examined for a predetermined period of
time to determine if first line therapies have been tried prior to second
line therapies being used.
Dispensing
particular medications only to patients receiving required concomitant
therapy. Whenever a prescription is presented for a specified
medication, the member profile is examined for a predetermined period of
time to determine if the required concomitant products have also been
provided.
Implementing
gradual restrictions for patients that have previously received reserved
medications. Whenever a prescription is presented for a reserved
therapy, the member profile is examined to determine if the same therapy
was previously dispensed within a predetermined time period. This allows
clients to "grandfather" reserved therapy for particular
patients, or phase in the therapy restrictions.
All of
our programs can be set to reject non-compliant claims, or return only an
advisory edit message. As determined by the client, overrides can be placed
in the system by the client’s review board, and/or by the dispensing
pharmacist with the use of selected intervention codes. Reports will allow
for monitoring how compliant the prescribers, pharmacies, and members are
with the therapy guidelines.
Selected
examples of how clients are currently using these edits:
- Dispensing second line NSAID’s (primarily the brand name items) to only
the patients that have been successfully treated with this second line
product within a predetermined time period.
- Requiring that a targeted
SSRI be only dispensed to patients that have already received it
within a previous time period.
- Requiring that selected
diabetes supplies be dispensed only to patients that have received
insulin within a predetermined time period.
- Requiring that Imitrex, Zomig, and Amerge be dispensed only to patients receiving
preventive migraine therapies.
- Dispensing second line
antipsychotics to only the patients that have been successfully
treated with a first line product within a predetermined time period.
You Make The Choices
PHARMCARE THERAPY
MANAGEMENT PLUS
PharmCare's Therapy Management Plus programs offer a
standardized approach for providing clinical, financial and marketplace
information to our health plan clients, their physicians and patients. By
educating them about the benefits and risks of therapy choices, we optimize
the quality and cost of care.
Targeting
patient populations and providing information regarding compliance and
therapeutic options encourages appropriate pharmacotherapy. Therapy
Management proactively enhances the appropriate prescribing of preferred
drug therapy regimens by providing evidence-based drug information to
providers and patients.
Each
therapy management program includes patient education material to help the
patient understand treatment. Many programs, including the lipid therapy
management program, provide members information on the importance of
medication compliance.
Key components of PharmCare’s
Therapy Management Plus programs include:
• Point of Reference Evidence-based
Guidelines/Newsletter
• Member Education Materials
• Preferred Drug Program
Reports/Materials
• Quality Assurance & Program
Impact Measurement
We
define therapy management as evidence-based and disease-focused programs
using pharmacy claims database as a 11 proxy"
for disease. Our programs are much like the disease management programs
that integrate medical claims data with pharmacy data. Each program is
developed, implemented and evaluated using the following guidelines:
• Data analysis
• Guideline development and
administration
• Quantifying financial and quality
opportunities
• Creating and implementing targeted
interventions
(e.g., treatment protocols, physician
letters, patient education materials)
• Program management
• Outcome measurement and finetuning
Currently
PharmCare offers or is developing the Therapy
Management programs to clients for:
• Gastroesophageal
Reflux Disease (GERD)
• Antibiotics
• Depression
• Diabetes
• Asthma
• Allergic Rhinitis
• Osteoporosis
• Hypertension
• Lipid Lowering Therapy
Education leads to improved therapy
choices.
You Make The Choices
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