Rx BENEFITS

Item # RXB1 – Priceline Style On-Line Marketplace for Rx Bidding                                                                                                                                                                                                          

This is an On-line Competitive Marketplace for Rx wherein Pharma Manufacturers compete first by posting their Choice of Products. Retail Pharmacies then compete by Bidding Prices Down so as to obtain Patient’s Business. Middle Man Margin’s get eliminated. Milliman Study showed 9.5 % Savings overall even if no Bidding. Comparison to Large PBM shows 42% Savings on Generics and 51% Savings overall when the Bidding Option is Fully Utilized. Can integrate with a PBM for Other Drugs not handled by this Marketplace   (U.S. Only)

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Item # RXB2 - Lowest Cost, Totally Transparent PBM               

This Privately Held, 10+ Year Old PBM uses Patient Safety and Clinical Soundness as the Primary Formulary Determinants - not Price/ Desired Profit Margins as with Publicly Traded PBM’s. Here, the Profit Margin is Disclosed Upfront and worked Backwards with Client to achieve while Transparently Considering All Revenue Streams such as PEPM’s, Rebates and Discounts. Average Savings of 6.5%+ or $6 per script, over Major PBM’s i.e. with 1% Trend (vs. 7% nationally), Money Back Guarantee all supported by Fully Transparent Reporting(U.S. Only)            

 Item # RXB3 Internationally Sourced, Employee Elective (Hence Permissible), Brand Name Drug Formulary                      

This is a Customized-to-Client Needs Formulary from Among a Master Formulary Representing 80% to 90% of all brand name drugs (300+). It is Employee Elective, Mail Order Only and Does Not Replace Current PBM. Drugs are sourced from Canada, UK, Australia, New Zealand and are Same Drug, Same Ingredients and Same Manufacturer as in US. Guaranteed savings is between 35%-55% over US pricing

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Item # RXB4 -Free-to-All Employees /Family Members Rx Discount Card                                                                                                   

Employees receive Cards from Either the Employer or Vendor and are then Auto=Enrolled at the Pharmacy Window. Network includes 95%+ of all National, Regional and Local Pharmacies that connect to the PBM which Re-prices the Drug. Brand Name Drug Discounts = 15% to 30% and Generic Drug Discounts = 55% to 65%(U.S. Only)

Item # RXB5 –Renowned and Independent Consultancy for Specialty / Biologics & Pharmaceutical Benefit Strategy Development

Specialty drugs now account for up to 1/3 of the total drug spend and 8-10% of the total healthcare plan spend (both growing rapidly). Managing these spends remains difficult given the high unit dollar amounts involved, cross-benefit impacts (i.e. both the Rx plan and the healthcare plan) and the employer's comparative inability to control such costs through traditional benefit plan design approaches and/or relying on TPA/PBMs for help. This retainer-based, independent consultancy has 30+ years of integrated health benefits consulting experience and 10+ years of concentration in the area of specialty Rx. They work with the client to determine current state and then to establish new integrated benefits coverage strategies, risk mitigation approaches, condition management processes, etc. These strategies impact both the pharmacy and medical benefits portions of the healthcare program and address the changing dynamics of specialty RX products to help achieve related business goals.

 

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Item #  RXB6 - PBM Audits Conducted by Non-Conflicted and Former PBM Insiders                                                                             

Other Auditing Firms may be Conflcited in that they also provide Potentially Conflicting Rx Benefit Plan Design and /or PBM Vendor Search Consulting Services. This Team of Highly and Diversely-Skilled PBM Auditing Professionals have started their own Break-Away Independent, PBM Auditing-Services-Only Practice. All Work is conducted on a Not-to-Exceed, Fee-for-Service Basis so as to Minimize Identification of “False Positives” Typically found by the Contingency Fee-Based Auditors that must then be disproven by the PBM under Some Time-Consuming Process                                                                           

Item # RXB7 Independent Physician-Developed RX Formulary

This Former ER Physician and Large Employer Medical Director is Non-Conflcited and Independent of any PBM and PBM Backroom Remuneration Schemes. He develops a Formulary that is customized to the Employer Needs and is based on Objective Clinical Input

Item # RXB 8 -Low/Lowest Cost Specialty / Biologics Carve-Out PBM                                                                                        

PBM’s typically share little or no rebates on specialty drugs with the Employer. This vendor instead negotiates substantial rebates for clients within a Specialty Rx PBM carve out that replaces that portion of the employers existing PBM.  To create transparency, this PBM discloses to the employer the itemized-by-drug rebate amounts that get collected from the manufacturer monthly and what amounts from those rebates the employer pays this PBM either in flat fees or as a percentage of the rebates. An RX repricing engine is available to assess the potential savings from this carve out against any increase in fees requested the existing PBM for its loss of the Specialty Rx piece. Typical savings have been in the range of X% to Y% of specialty Rx spend  

Item # RXB9 – Potentially Free, PBM Optimization Consulting Services Performed by a Mail Order Drug Provider/ Insider

This “VIPPS” Accredited (like Walgreens) On-Line Mail Order Drug Company will audit your Current PBM by Re-Pricing High Utilization Brand Name and Generic drugs to see which Drugs can be provided at a lesser Cost and to disclose Actual PBM Pricing Tactics. It can also test the Veracity of the Specialty Drugs List and Design a “Next Tier of OTC’s” whereas most PBMs are Conflcited from doing either. Consulting Services are Free but only if this Vendor become your Mail Order Drug Vendor

 

Item # RXB10 - Patented Process for Beneficially Managing Mental Health (Psychotropic) Drug Usage by Plan Members thereby Reducing Drug Spending and the Related Healthcare, Disability and Workers Comp Costs while Improving Productivity

 

Typically 15% to 20% of healthcare plan members are being prescribed mind altering /psychotropic drugs by non-specialized / regular physicians without any scientific assessment of either the initial diagnoses or the propriety for continued usage as symptoms change going forward. With respect to direct costs, among the top 5 therapeutic classes of drugs, psychotropic are third largest representing 21% of the total spend. The indirect costs outweigh these direct costs and can include unnecessary claims in healthcare, disability and workers comp plus lost productivity. This consultancy deploys a comprehensive patented process that also incorporates a mental-health-coach-supported and telephonically-delivered Hospital Anxiety / Depression (HAD) screenings. The HAD screenings are used for initial and ongoing diagnoses in coordination with the members’ prescribing physician on clinical outcomes. A free upfront analytic assesses the scope of problem and establishes the requisite and at-risk-for-success pepm. In one case, savings in the targeted psychotropic direct drug spend was reduced by 30% with a similar percent of indirect savings in the healthcare spend

 

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Item # RXB11 – Contingency-Fee-Based Specialty Pharma Cost Management Program Supported by a Proprietary Network of Licensed Specialty Pharmacy Drug Providers  

 

Specialty drug spending is projected to approximate 40% of all drug spending by 2020. This Specialty Pharmacy Management (SPM) program is supported by a proprietary network of licensed specialty pharmacy drug providers. Providers can dispense and deliver specialty drugs to a patient’s home, work, infusion center, physician’s office or outpatient clinic. SPM cost savings techniques include transferring the specialty drug prescription and shipping the specialty drug to the patient or provider for administration; setting up specialty drug skilled-nursing care combined with first-time fill of specialty drug or transferring the specialty-drug prescription to an in-network  specialty pharmacy provider that ships the specialty drug to the patient for infusion. The average savings on successful claims is 29% or more than $5,200 per claim.  

 

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# RXB12 - Prescription Drug Price Transparency Tool that uses Push Technology to Change Plan Member Behavior so as to Contain Spending

 

Traditional and closed end Rx solutions like formulary plans, PBMs, mail order programs, rebates, etc. have run their course in terms of generating additional savings. This transparency software instead uses the PBM's data files to determine prescriptions being taken by plan members and the prices thereof. Then, this healthcare consumerism platform searches proprietary contracts and all available discounts available via the internet and returns to the member where and how to secure the lowest available price for that particular prescription.  Via the use of email, text messaging, etc. the system proactively educates plan members with a personalized action plan to save them (and the employer) money. e.g. "A prescription drug savings opportunity of $562.83 has been identified for you. Log-in to your account to learn more!" On average, employers are overspending by 22% in this regard.

 

 

Item# RXB13 – Free-to-User, Fully-Automated PBM and Rx Stop-Loss Quotation Engine for Small and Mid-Sized Employers

 

Obtaining quotes for Rx coverage and Rx stop loss insurance requires a significant level of expertise and can be time consuming if performed using traditional, manually populated spreadsheets.  This free -to –use, parameter driven system automatically generates Rx benefit and stop loss quotes for easy comparison. The annual drug spend, total covered lives and if stop loss is being quoted, 12 months of claims data are entered into the system which then generates side-by-side comparative quotes from a prepopulated stable of leading PBM and  / or insurance carriers – all within minutes. Detailed reports that analyze each vendor including three-year financial projections, formulary disruption and network access are auto generated.  This information is used to select the RX plan and/ or stop loss policy that best meets the employer’s needs. Then, the PBM contract and / or stop loss application is / are made available on-line within minutes of contract award.  Once a plan goes live, quarterly reports evaluate the PBM performance relative to its annual guarantees and present an overview of key utilization metrics so as to provide a clear understanding of the vendor’s financial integrity and processing accuracy.

 

Item# RXB14 – “App”  for Plan Members to Access RX Benefit Plan Rules, Local Rx Pricing, Specific-to-Member Out-of Pocket Plan Costs and Manufacturer  RX Discounting Opportunities  

 

Rx plan members have become subject to increasingly complex / hard-to-understand plan designs, onerous preauthorization requirements (resulting in a 40% process dropout rate)and a continually increasing out-of-pocket Rx spend - all of which combine to reduce medication adherence.  This 2+ years-in-the-making, free-to-member Rx consumer application provides real-time access to pharmacy benefit plan and drug cost information. Members download the app, and set up a login and access real time / anywhere access to:

 

     -Drug coverage rules – prior authorization, step therapy, exclusions

     -Drug cost – copay, deductible, coinsurance, cash pay

     -Savings opportunities – drug coupons, links to patient assistance programs

 

For members, this tool provides transparent, upfront knowledge of Rx costs and benefits, optimizes their Rx spending and eliminates the pharmacy’s messaging of “Your plan requires a call. Come back tomorrow.” For employers, it increases member satisfaction with the plan and increases Rx adherency rates.

 

 

Item# RXB15 – Contingency Fee-Based, Rx Audit and ERISA Plan Asset Recovery Service

 

All / most other Rx audit services vendors focus on identifying anomalies and overpayments related to areas such as contract adherence on discount guarantees, mis- categorization of drugs, benchmark unit pricing, etc. However, once the errors are identified, the vendors fail to recoup the funds / ERISA plan assets as required by law. This service provider offers a free-upfront audit of the last 12 months’ worth of Rx claims in order to assess the potential opportunity. If the client desires, thereafter the vendor will audit the remaining open years and retain a percent of savings contingency fee. Conservatively, the program recovers between 2-4% of the total pharmacy spend over a 2 to 3 year retrospective audit of 100% of paid pharmacy claims. An optional PEPM -based on-going monitoring and pricing concession service typically produces between a 5% and 10% additional savings. 

 

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Item # RXB16 –Cost Management Service for RX Benefit Plans Driven by Evidence-Based Therapeutic Alternative Identification and Substitution so as to Affect an Average 15% Savings

 

Drug recommendations are oftentimes influenced by marketplace forces (e.g. PBM profits, duly entertained physicians, advertisements, couponing, etc.) to use costly brand name drugs when in fact, already existing and less costly therapeutic alternatives could be prescribed if generics are not available. This services provider uses a university’s noted and top-ranking college of pharmacy’s evidence-based research to identify and drive usage of therapeutic alternatives. The process begins with a no-cost upfront savings analysis tool that identifies the target population and quantifies the impact of the recommended strategies for both the plan and the members .The vendor works with any willing PBM and drives participation in this voluntary usage program directly with employees and prescribing physicians using proven communication outreach programs and a pharmacist-supported call center. This service requires little involvement from HR and is charged for on a flat fee per claim basis. Employers will typically save between 12 and 17% per year and employees will also see a reduction in their out-of-pocket costs     

 

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Item# RXB17 - Pre-Authorization, Competitive Bidding and Manufacturers’ Discount-Based, Specialty Pharma Purchasing and Access Program that Produces Significant Savings

  • Specialty Meds are projected to account for 50% of the employer’s Rx spend by 2020
  • This team of non-PBM-affiliated (thus, financially objective)  doctors and pharmacists;
    • -provides an independent, unbiased Prior Authorization
    • -shops over a dozen of the nation’s most competitive Specialt
    • -re-designs the Rx benefit plan to allow employees to qualify for Manufacturer’s Assistance
  • Results have been a 70+% employer savings on select Rx’s and at the employer’s option, a $0 Rx plan member co-pay for specialty meds
  • A contingency fee is paid from the savings on each drug 

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Item# RXB18 - Integrated Usage and Acquisition Process for Reducing Specialty Rx Program Costs 

 

Many specialty drugs are being prescribed on an experimental basis for diagnoses where the use of the drug has not been tested and /or where the drug has been shown that it does not work for many / the majority of patients based on clinical trial results. To solve these problems, a management process was developed by veterans of the pharmaceutical and related industries to manage the patient’s access to and supply of specialty drugs. The process begins by assuring appropriate usage based on label instructions vs experimentation by the prescribing physician. Drug effectiveness is then proven out by testing and measuring to know when and for which patients a given drug can actually work. Once a drug is shown to be appropriate and effective, an automated acquisition process assures the best price and delivery method. Actual savings range from 15% to 25% of specialty drug costs and can be estimated in advance by analyzing the employer’s specialty Rx data.         

 

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