Pharmacy Benefit Savings
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Clinical Technology Intelligence (CTIRx®)

Goal: To promote clinically appropriate prescription drug utilization resulting in positive health care outcomes adjunct to pharmacy benefit savings.

PBIRx® has a diverse clinical staff of pharmacists with experience in several areas of pharmacy including community pharmacy, clinical pharmacy, drug manufacturing companies, and academia.

Pharmacists work closely with PBIRx® analytical experts in the PBIRx® Informatics Group to review client drug trend for both high cost specialty medications and all "other prescription drugs".

PBIRx® Clinical Responsibilities:

Pre Implementation

PBIRx® will run client claims through CTIRx® data processor with over 100 various drug management strategies. These include various step care therapies, prior authorizations, exclusions and coverages of Over-The-Counter (OTC) products. PBIRx® clinical management strategies include various degrees of medication management depending on Client goals. Strategies can be stratified over various phases non-grandfathering. Estimated savings is provided along with member disruption.

Post Implementation

Use client claims data to deliver actionable information for clinical pharmacy savings strategies resulting in high quality cost effective pharmacy management and positive health care outcomes.

  • Monthly analysis of cost and claims both specialty and all "other prescription drugs"
  • PBIRx® proprietary clinical algorithms identify PBIRx® proprietary clinical savings programs
    • Clinical program opportunities, member disruption, and savings provided to client
    • Continuum based recommendations (ongoing) include, but are not limited to formulary changes, prior authorizations, step therapies, quantity limits
    • PBIRx® facilitates implementation, member/physician communication, quarterly savings reports
    • Non adherence analyzed for member specific programs
    • Coupon utilization preferring higher cost drugs versus equally therapeutic equivalent drugs analyzed
  • Review of physician prescribing practices
    • Prescriber Report Cards
    • Inappropriate prescribing
    • Brand versus generic prescribing
    • Fraud, Waste, & Abuse
    • E-prescribing trends
  • Specialty Drug Tool Box
    • Internally built to increase knowledge and access to specialty disease information
    • Enables PBIRx® to proactively manage specialty spend
    • Provides pathway to positive clinical and pharmacoeconomic outcomes
  • Medical "J" code review and carve out/savings review and analysis
    • Analysis of prescription pricing dispensed through medical "J" code versus through pharmacy benefit
    • Client specific strategic implementation plan developed with savings for moving drug dispensing through pharmacy benefit for certain drugs
    • Moving specialty drugs to the pharmacy benefit would result in:
      1. Uniform application of patient cost-share, clinical management, and utilization management
      2. Elimination of challenges in drug coding, data integration, billing, and payment
  • Proactive new drug awareness and research
    • Opportunity to implement appropriate prior authorization, step therapy and/or quantity limits to mirror manufacturer instructions prior to member utilization
  • Reporting
    • Manufacturer AWP increases
    • Utilization of new drugs
    • Identify primary trend drivers by "other drugs" and high cost "specialty drugs"

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