Third Party Financial Issues An Overview of Managed Care With a Dash of Humor
Your company's new health plan will cover your heart surgery but changes in your co-pay mean we take your liver.
What exactly is health insurance? <ul><li>A program that helps its members obtain the healthcare services they need by red...
Overview of Rx Drug Benefits: Balancing Costs and Access <ul><li>Health Maintenance Organization Act of 1973 </li></ul><ul...
Forces Driving Drug Costs <ul><li>Utilization </li></ul><ul><ul><li>Aging population </li></ul></ul><ul><ul><li>New medica...
 
The  Payers   and the  Players <ul><li>Health Plans </li></ul><ul><ul><li>Indemnity or Fee for Service </li></ul></ul><ul>...
Payers and Players  cont. <ul><li>Employer </li></ul><ul><ul><li>Premiums </li></ul></ul><ul><li>Employee  (Subscriber) </...
 
Formularies: Clinical and Cost Containment Perspective <ul><li>Formulary </li></ul><ul><ul><li>Open </li></ul></ul><ul><ul...
More Rx Cost Containment Tools <ul><li>Prior Authorizations (PA) </li></ul><ul><li>Step therapy </li></ul><ul><li>Supply l...
Pharmacy Impact  85-90% of prescriptions ‘touched’ <ul><li>Customer Service </li></ul><ul><ul><li>Explaining benefit issue...
Computer & 3 rd  Party <ul><li>On-line adjucation </li></ul><ul><li>Dispense as Written (DAW) </li></ul><ul><ul><li>0  no ...
 
Economics  Incentive Programs <ul><li>Pharmacy Reimbursement </li></ul><ul><ul><li>Contracted rates </li></ul></ul><ul><ul...
MEDICAL (California) <ul><li>Eligibility </li></ul><ul><li>Treatment Authorizations Requests (TARs) </li></ul><ul><ul><li>...
Medical Cards
Medicare Rx Drug Benefit <ul><li>What is it? </li></ul><ul><li>Who is it for? </li></ul><ul><li>When does it begin? </li><...
<ul><li>Standard Benefit </li></ul><ul><li>Average $30/mo </li></ul><ul><li>Drug Formularies </li></ul><ul><li>Tiered Co-p...
Medicare Rx Resources <ul><li>www.medicare.gov </li></ul><ul><ul><li>Select ‘Prescription Drug & Other Assistance’ </li></...
 
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Third party Financial Issues

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Third party Financial Issues

  1. 1. Third Party Financial Issues An Overview of Managed Care With a Dash of Humor
  2. 2. Your company's new health plan will cover your heart surgery but changes in your co-pay mean we take your liver.
  3. 3. What exactly is health insurance? <ul><li>A program that helps its members obtain the healthcare services they need by reducing the risks of financial exposure </li></ul><ul><li>Risks are minimized by spreading financial costs and risks over a large group of members in the plan. </li></ul>
  4. 4. Overview of Rx Drug Benefits: Balancing Costs and Access <ul><li>Health Maintenance Organization Act of 1973 </li></ul><ul><ul><li>Addresses Rising Healthcare Costs </li></ul></ul><ul><ul><li>Defined HMO Federal Requirements </li></ul></ul><ul><ul><li>Led to proliferation of HMO’s </li></ul></ul><ul><li>Medicare Rx Drug Improvement & Modernization Act </li></ul>
  5. 5. Forces Driving Drug Costs <ul><li>Utilization </li></ul><ul><ul><li>Aging population </li></ul></ul><ul><ul><li>New medical treatment guidelines </li></ul></ul><ul><ul><ul><li>Aggressive use </li></ul></ul></ul><ul><ul><li>Available new expensive treatments </li></ul></ul><ul><ul><ul><li>Demand </li></ul></ul></ul><ul><ul><ul><li>Quality of life </li></ul></ul></ul><ul><ul><li>Specialty pharmaceuticals </li></ul></ul>
  6. 7. The Payers and the Players <ul><li>Health Plans </li></ul><ul><ul><li>Indemnity or Fee for Service </li></ul></ul><ul><li>Managed Care </li></ul><ul><ul><li>HMO, PPO </li></ul></ul><ul><ul><li>Pharmacy Benefit Managers (PBM) </li></ul></ul><ul><li>Public Health Insurance </li></ul><ul><ul><li>Medicare </li></ul></ul><ul><ul><li>Medicaid </li></ul></ul><ul><ul><ul><li>Medi-Cal </li></ul></ul></ul><ul><ul><ul><ul><li>Tars/E-Tars </li></ul></ul></ul></ul><ul><ul><ul><li>CCS-California Child Services </li></ul></ul></ul>
  7. 8. Payers and Players cont. <ul><li>Employer </li></ul><ul><ul><li>Premiums </li></ul></ul><ul><li>Employee (Subscriber) </li></ul><ul><ul><li>Dependants </li></ul></ul><ul><ul><li>Deductible </li></ul></ul><ul><ul><li>Out of Pocket Costs </li></ul></ul><ul><ul><li>Co-pay versus Coinsurance </li></ul></ul>
  8. 10. Formularies: Clinical and Cost Containment Perspective <ul><li>Formulary </li></ul><ul><ul><li>Open </li></ul></ul><ul><ul><li>Closed </li></ul></ul><ul><ul><li>Limited </li></ul></ul><ul><li>Multi-tiered Benefit Design </li></ul><ul><ul><ul><li>Single tier </li></ul></ul></ul><ul><ul><ul><li>Two-tier </li></ul></ul></ul><ul><ul><ul><li>Three-tier </li></ul></ul></ul><ul><ul><ul><li>Four-tier </li></ul></ul></ul>
  9. 11. More Rx Cost Containment Tools <ul><li>Prior Authorizations (PA) </li></ul><ul><li>Step therapy </li></ul><ul><li>Supply limit </li></ul><ul><li>Refill to soon rejection </li></ul><ul><li>Drug Utilization Review (DUR) </li></ul><ul><li>Great differences between copay tiers </li></ul><ul><li>Mail order service </li></ul>
  10. 12. Pharmacy Impact 85-90% of prescriptions ‘touched’ <ul><li>Customer Service </li></ul><ul><ul><li>Explaining benefit issues </li></ul></ul><ul><ul><li>Empathy & communication </li></ul></ul><ul><li>Patient education & managing expectations </li></ul><ul><li>Third Party Processing </li></ul><ul><ul><li>Eligibility Issues </li></ul></ul><ul><ul><li>EDS </li></ul></ul><ul><ul><li>NDC not covered </li></ul></ul><ul><ul><li>DAW </li></ul></ul><ul><li>Common </li></ul><ul><ul><li>Rejections </li></ul></ul><ul><ul><li>Top 10 3 rd party </li></ul></ul>
  11. 13. Computer & 3 rd Party <ul><li>On-line adjucation </li></ul><ul><li>Dispense as Written (DAW) </li></ul><ul><ul><li>0 no DAW </li></ul></ul><ul><ul><li>1 md requested brand </li></ul></ul><ul><ul><li>2 pt requested brand </li></ul></ul><ul><ul><li>3 rph selected brand </li></ul></ul><ul><ul><li>4 generic not in stock </li></ul></ul><ul><ul><li>5 brand dispensed but priced as generic </li></ul></ul><ul><ul><li>6 n/a </li></ul></ul><ul><ul><li>7 substitution not allowed, brand mandated by law </li></ul></ul><ul><ul><li>8 generic not available </li></ul></ul>
  12. 15. Economics Incentive Programs <ul><li>Pharmacy Reimbursement </li></ul><ul><ul><li>Contracted rates </li></ul></ul><ul><ul><li>Payment terms </li></ul></ul><ul><li>Increasing Generic Dispensing </li></ul><ul><li>Formulary Compliance </li></ul><ul><li>Customer Service Surveys </li></ul><ul><li>Cognitive Services </li></ul><ul><li>Wellness Programs </li></ul>
  13. 16. MEDICAL (California) <ul><li>Eligibility </li></ul><ul><li>Treatment Authorizations Requests (TARs) </li></ul><ul><ul><li>Etars </li></ul></ul><ul><li>ID numbers </li></ul><ul><li>Date of Issue </li></ul>
  14. 17. Medical Cards
  15. 18. Medicare Rx Drug Benefit <ul><li>What is it? </li></ul><ul><li>Who is it for? </li></ul><ul><li>When does it begin? </li></ul><ul><li>Which is the best plan for me? </li></ul><ul><li>New Challenges and Confusions </li></ul><ul><li>Where is the information? </li></ul>
  16. 19. <ul><li>Standard Benefit </li></ul><ul><li>Average $30/mo </li></ul><ul><li>Drug Formularies </li></ul><ul><li>Tiered Co-pays </li></ul><ul><li>Prior Authorizations </li></ul>
  17. 20. Medicare Rx Resources <ul><li>www.medicare.gov </li></ul><ul><ul><li>Select ‘Prescription Drug & Other Assistance’ </li></ul></ul><ul><ul><li>1-800-MEDICARE </li></ul></ul><ul><li>www.RxSavingsAccess.com </li></ul><ul><ul><li>1-800-CARD4RX </li></ul></ul><ul><li>www.Together-Rx.com </li></ul><ul><ul><li>1-800-865-7211 </li></ul></ul>

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