Feeling the Benefit

There are many PBM companies out there vying for your business. You need to make sure that you ask how much experience they have in handling workers’ compensation claims. As laws vary from state to state, a PBM that specializes in workers’ compensation understands these regulations and how they affect claimant pharmacy needs. It is important to consider asking questions about how many years the PBM been working in workers’ compensation and whether it can provide references, workflows and processes specific to the area. It is also worth checking that there is a dedicated team for workers’ compensation and finding out how the PBM stays current in the industry.

Some PBMs lack a comprehensive workers’ compensation national pharmacy network. This is an important aspect because program savings are not realized if the claimant fills their prescription out of network, due to provider coverage issues. A PBM’s network should offer claimants access to a large number of pharmacies wherever and whenever they need prescriptions. Find out if the network includes national pharmacy providers and that the list of networked pharmacies is available to claimants, easy to access and updated regularly.

Also check how new pharmacies are recruited into the network and what retail network quality assurance measures are used to ensure retail pharmacies are meeting contractual obligations?

Drug utilization review (DUR) is the backbone of an effective program. Without a process of clinical review at each step of the claim lifecycle, the risk of paying for medications that are unrelated to the claimant’s injury is increased. It is critical to understand what the PBM vendor includes as part of its DUR process.

Is the formulary created and managed by physicians and pharmacists, what is the concurrent (point-of-sale) program and what specifically does the program monitor? Furthermore are intervention programs offered, can pharmacists be reached for questions and are prescribing physicians proactively contacted on questions? Finally, find out how mail order claims and retail claims are monitored together and make sure you understand the proactive conversion process of claims to mail order services.

The ability to integrate a PBM’s technology with existing business applications is important. It is essential for a PBM to offer flexible, customizable solutions that meet the company’s specific requirements while not interrupting current technology projects. Some questions to consider are how the technology integrates with existing applications, can it be customized to meet specific business needs, what technology platforms are utilized and will they integrate, and does the PBM have EDI capabilities?

Being able to measure the PBM’s impact and effectiveness in saving time and money without sacrificing quality and ease of use for the claimant is important. Appropriate reports allow you to monitor the PBM and allow you to continually benchmark and analyze the pharmacy spend for your claimants. Think about the following:

• What types of reports are offered?
• What file formats of the reports are offered?
• Can reports be delivered electronically and securely?
• Are the reports "real time" or “retrospective”?
• Can reports be customized?
• Is there a charge for reports?

A PBM partnership isn’t just a group of easy to use programs that assist the claims professional with daily job functions. It must also meet the needs of management in monitoring the relationship and the associated pharmacy costs. With some due diligence you will be on your way to a great long-standing pharmacy benefit management relationship.

About Tron Emptage
Tron Emptage is VP of Strategic Initiatives for Progressive Medical, Inc. He has over 16 years of pharmaceutical experience including expertise in all aspects of the delivery of pharmaceutical care. He also leads the National Account Services team, as well as developing new pharmacy, clinical and technology product solutions for Progressive Medical’s clients.