First Line of Defense:
Our OneArk™ Suite
Our proprietary software works as a semi-permeable membrane against bad claims. OneArk™ avoids waste and inaccuracies at the Point of Sale (POS) through the integrated application of clinical, administrative and market knowledge. These are the most effective tools to combat the increase in costs and utilization. It also helps to improve services and CMS compliance through real-time tools that proactively resolve issues at the POS.
Take a look at some examples of how OneArk™ defends your finances:
Accurate duplicate therapy edits
OneArk™’s Exception Tool helps us eliminate inaccurate edits and/or messages to pharmacies through our Drug Utilization Review Program. Our duplicate therapy criteria are totally customizable based on P&T decisions. This way, real duplicate therapies are recommended as hard rejects. For example:
- PharmPix does not recognize Metformin and Glyburide as a duplicate therapy like most other PBMs do.
- Albuterol Inhalation Nebulization Solution is not treated as a duplicate therapy with ProAir HFA Inhalation Aerosol Solution.
Accurate claims quantities
Many drugs, because of their dosage form, or packaging, are more likely to be submitted by pharmacies in incorrect quantities (such as insulin, eye drops, enoxaparin and many others), confusing strength in milligrams with milliliters. PharmPix has created a POS logic that effectively avoids these errors.
Drug pricing examples
- Date of Service Based Adjudication Program: Branded drug prices increase once or twice a year and many pharmacies’ software are set up to reverse and then re-submit branded claims so that the claims can be adjudicated at the higher price. When processing the requested adjustment, PharmPix’s system looks for the date of service and adjudicates accordingly, resulting in a net $0 adjustment.
- POS (Point of Sale) alert system: A real-time alert queue keeps our clients aware of what’s going on at the POS and provides a tool to proactively manage prior authorizations.
- Client set up and management changes: OneArk™ Cube is a tool designed to set up a client and make changes to existent designs/formularies in just minutes.
CMS Compliance examples
- Real time CMS member transition program: OneArk™ EDI allows claims not otherwise covered by the plan (non-formulary drugs) in the transition period and creates an automatic letter that is sent to the member. The process at the POS is transparent for the member and compliant with CMS rules and regulations. A message is also sent to the pharmacy indicating that “this claim has been paid through the transition program, please provide counseling to the member”.
- CMS-protected categories: OneArk™ EDI allows claims edits, such as PA, in these categories only for new starts. When members come back for their medication, the system will not request another PA because the system will detect that the member has been in this drug therapy before. This happens even if there is a new prescription for the drug in question. Our experience shows that all of these tactics save from 0.5% to 1% of total pharmacy costs and provide 100% compliance with CMS rules.
Second Line of Defense:
We manage formularies based on the lowest net cost and consider drugs that are losing patents:
- Formulary management is based on the lowest net cost and considers drugs that are losing patent by category. Drugs are not considered in a silo, rather they are considered as the place in therapy within appropriate categories.
When evaluating new drugs, PharmPix P&T Committee also considers, whenever available, the concepts of:
- Relative Risk Reduction (RRR) vs. Absolute Risk Reductions (ARR): these are concepts important to understand when evaluating drugs since depending on the one being used, the drug can be seen more powerful or efficacious than it really is. Example: In a placebo controlled, 3-years clinical trial, in the group using Drug A, there was 1 heart attack in a sample size of 100, however there were 2 cases of major bleedings that needed discontinuation of the drug vs. in the placebo group there were 2 heart attacks in a sample size of 100 without major bleeding events.
- Applying the concept of RRR gives it a risk reduction of 50%
- Using the concept of ARR gives it a risk reduction of just 1%
- Number Needed to Treat (NNT): this concept helps to assess the efficacy of drugs in the real perspective. In the same trial as above, the NNT for Drug A is equal to 100, which means that you have to treat 100 members for 3 years with Drug A to prevent 1 heart attack event.
- Number Needed to Harm (NNH) is the same concept as NNT, but related to a given side effect. In the same trial as above, NNH is equal to 50, which means that while treating 50 members with Drug A you most probably encounter 1 major bleeding.
Therefore, when evaluating the drug against all of this information and/or available concepts, the P&T Committee will have a clearer picture and can make a more informed decision.
Third Line of Defense:
Competitive Delivery Channels
Aggressive network contracting and a dynamic MAC list with auditing protocols truly targets inconsistencies in the pharmacy network.
- Detailed pharmacy profiling
PharmPix’s clinicians profile pharmacies with sufficient volume in the following criteria:
- % of refills
- % of reversal of refills
- Cost per unique member
- Rxs per unique member
- % of partial fills
- DUR success rates
- Competitive Mail Order Contracts: PharmPix believes in using an external mail service provider in order to drive healthy price competition for our client plan sponsors. PharmPix also continues to review the latest, best-in-class methods for managing chronic medication delivery via mail service in order to provide our plan sponsor clients with up-to-date technology, improved member services and quality of care.
- Competitive specialty pharmacy contracting with Specialty PA Program: We believe in providing our clients with several options for Specialty service providers in order to drive a healthy price competition for our client plan sponsors.
In some cases, we also believe that certain therapies are better filled in a retail pharmacy when fraud and abuse might be a concern. PharmPix also continues to review the latest, best-in-class methods for managing specialty pharmaceutical delivery in order to provide our plan sponsor clients with up to date technology, member services and quality of care.
In addition to our distribution partnerships, we monitor the approval rate of the PA program. We believe that a program with more than 87% approval rate will not achieve the desirable ROI of 2.5:1. Also, our specialty program monitors members from the PA throughout the life of the usage based on effectiveness and safety. For example:
- Enbrel: A costly drug indicated for RA. The criteria for approval include the assessment of the members' profile, looking for recent flu-like symptoms or current treatment for active infections. If active infection is confirmed, we recommend holding approval until the infection is healed. This medication can be harmful to patients with active infections, increasing the risk of death. This way, we flag complications before they even arise.
- Forteo: A costly medication indicated for osteoporosis. The criterion includes assessment of the effectiveness of the drug 6 months after the start of therapy. It is an established fact that if the medication has not worked in the first 6 months of therapy, it never will. This way, another therapy can be tried as soon as possible.
PharmPix’s Step Therapy, Qantity Limit and Time Duration Programs are created by our Clinical Team based on primary literature and clinical guidelines. The programs are then reviewed and approved by our independent P&T Committee. We accommodate clients’ criteria per client request.BACK TO TOP
Fourth Line of Defense:
Utilization Management Program
The most accurate edits point out risks to members and waste to the client. All criteria are created and updated by our P&T Committee based on FDA indications, Micromedex Effectiveness and Safety Info, and primary literature review. Our set of programs include.
- DUR Program: Through our exception tool in OneArk™, we have created the most accurate edits so we are able to recommend the rejection of real DURs that represent a risk of harm to the member or a waste to our client.
- PA Program: PharmPix’s Prior Authorization Program was designed to assure the right patient is getting the right drug at the right time, in the right dose, for the right extension of time.
We place special attention on efficacy and safety, for example:
- Enbrel: A costly drug indicated for RA. The criteria for approval include, among others, to assess the member’s profile for recent flu like symptoms or active infection medications. "This medication can be harmful to patients with active infections, increasing the dead risk". If an active infection is confirmed, we recommend holding approval until the healing is done.
- Forteo: A costly medication indicated for osteoporosis. The criterion includes assessing the effectiveness of the drug 6 months after the member starts taking the drug. It is well known that if the medication has not worked within the first 6 months of therapy, it never will.
- Step Therapy Program
- Qty Limits (same as DUR and ST)
- Time Duration
PharmPix’s Step Therapy, Qty Limit and Time Duration Programs are created by our Clinical Team based on primary literature and clinical guidelines. The programs are then reviewed and approved by our independent P&T Committee. We accommodate clients’ criteria per client request.BACK TO TOP
Fifth Line of Defense:
Highly targeted programs reduce the chance of drug-related problems, manage therapy and disease, target branded drugs and replace them with cost-effective ones, optimize dosage and educate benefit members. Look into the details.
- MTMP for asthma, congestive heart failure, hyperlipidemia and high blood pressure: These programs are focused on reducing the chance of drug-related problems, such as drug-drug interactions, drug-disease interactions, under and over utilization, disease not treated and drug being used without a diagnosis.
- Disease management: Based on medical and pharmacy data integration our system detects gaps in therapy with an education component that targets members and providers. For example:
- Therapeutic Interchange targets branded drugs with no generic available but generics available in the same category.
- Dose Optimization targets drugs that have the same price across the different strengths and can be given once a day or more often.
- Education targets drug-adherence interventions with members.
Sixth Line of Defense
Our Consultation Support includes, but is not limited to, the following:
We start with our periodic KPI report that gives clients a high-level sense of what is going on with their pharmacy benefit and shows
- PMPM Plan Cost
- Drug Mix Indicators
- Pricing Indicators
- Utilization Indicators
- Cost Share Indicators
Based on where the opportunities reside with each clients’ pharmacy benefits plan, other, more specific reports are produced that will guide us on how to go about the opportunities detected. These other reports include, among many others:
- Top 100 Pharmacies
- Top 100 Medications
- Top 100 Physicians
Once we come up with these detailed, customized reports, we help our clients create the necessary strategy to approach these opportunities.
All are framed within aggressive Compliance and Quality Programs, and a service-level agreement that include, among other things:
- CMS Coverage Determination and Appeal Process
- PDE Management
- PDE-Claims Reconciliation Tool
- Transition Plan
- CMS 5-Stars Rating Program
- Performance Guarantees