Third Party Financial Third Party Financial IssuesIssues

An Overview of Managed Care

With a Dash of

Humor

What exactly is health insurance?

A program that helps its members obtain the healthcare services they need by reducing the risks of financial exposure

Risks are minimized by spreading financial costs and risks over a large group of members in the plan.

Overview of Rx Drug Benefits: Balancing Costs and Access

Health Maintenance Organization Act of 1973– Addresses Rising Healthcare Costs– Defined HMO Federal Requirements– Led to proliferation of HMO’s

Medicare Rx Drug Improvement & Modernization Act

Forces Driving Drug Costs

Utilization– Aging population– New medical treatment guidelines

• Aggressive use

– Available new expensive treatments• Demand

• Quality of life

– Specialty pharmaceuticals

The Payers and the Players

Health Plans– Indemnity or Fee

for Service Managed Care

– HMO, PPO– Pharmacy Benefit

Managers (PBM)

Public Health Insurance– Medicare– Medicaid

• Medi-Cal– Tars/E-Tars

• CCS-California

Child Services

Payers and Players cont.

Employer– Premiums

Employee (Subscriber)

– Dependants– Deductible– Out of Pocket Costs– Co-pay versus

Coinsurance

Formularies: Clinical and Cost Containment Perspective

Formulary– Open– Closed– Limited

Multi-tiered Benefit Design• Single tier• Two-tier• Three-tier• Four-tier

More Rx Cost Containment Tools

Prior Authorizations (PA) Step therapy Supply limit Refill to soon rejection Drug Utilization Review (DUR) Great differences between copay tiers Mail order service

Pharmacy Impact 85-90% of prescriptions ‘touched’

Customer Service– Explaining benefit

issues– Empathy &

communication

Patient education & managing expectations

Third Party Processing– Eligibility Issues– EDS– NDC not covered– DAW

Common – Rejections– Top 10 3rd party

Computer & 3rd Party

On-line adjucation Dispense as Written (DAW)

– 0 no DAW– 1 md requested brand– 2 pt requested brand– 3 rph selected brand– 4 generic not in stock– 5 brand dispensed but priced as generic– 6 n/a– 7 substitution not allowed, brand mandated by law– 8 generic not available

Economics Incentive Programs

Pharmacy Reimbursement– Contracted rates– Payment terms

Increasing Generic Dispensing

Formulary Compliance

Customer Service Surveys

Cognitive Services Wellness Programs

MEDICAL (California)

Eligibility Treatment Authorizations Requests

(TARs)– Etars

ID numbers Date of Issue

Medical Cards

Medicare Rx Drug Benefit

What is it? Who is it for? When does it begin? Which is the best plan

for me? New Challenges and

Confusions Where is the

information?

Standard Benefit Average $30/mo Drug Formularies Tiered Co-pays Prior Authorizations

Medicare Rx Resources

www.medicare.gov– Select ‘Prescription Drug & Other Assistance’– 1-800-MEDICARE

www.RxSavingsAccess.com– 1-800-CARD4RX

www.Together-Rx.com– 1-800-865-7211