No-fault medical losses cost payers an estimated $18 billion in 2013. Of this amount, nearly $9 billion is attributed to personal injury protection (PIP), with pharmacy-related claim expenses just shy of $1 billion, or roughly 11 percent of total PIP claim payments.
Nearly $1 billion in pharmacy-related claim expense is meaningful. When compared to workers’ compensation, the average price per prescription was 30 percent higher and the average number of prescriptions per claim was 220 percent greater. There’s an opportunity for payers and injured workers to benefit from a pharmacy benefit manager (PBM).
PBM services help payers make better decisions, delivering claim-handling efficiencies. They offer insight into claim activities that might be high-risk or high-cost, and provide the tools to intervene should it be necessary. A PBM’s pharmacy network assures access to medications and reduces costs through network discounts.
For the injured party, the PBM offers convenience. Not only are injured parties able to more easily obtain claim-related medications, but they can also gain access to home delivery services, and need not submit pharmacy receipts for reimbursement of out-of-pocket costs. These conveniences are essential to customer satisfaction and policy retention.
There are more than two million auto injuries in any given year. Physicians will prescribe medications to many, if not the majority, of cases. Therefore, a payer’s ability to ensure the injured party receives the right medication at the right time, and at the right price, is significant.
Key Features of a PBM Program
When looking for a PBM, a no-fault payer should look for programs that provide excellent service, an extensive pharmacy network, evidence-based clinical programs, and advanced technology and reporting tools. Analytic insight and veteran industry expertise, advocacy in government affairs, competitive pricing and expertise with catastrophic care coordination also are important.
Key Program Features
- Excellent Service: The ability to provide accountable service is critical. Payers should look for accessible service associates, passionate account management and visible, engaged leadership. Tools, resources and support should be available when you need them.
- Extensive Pharmacy Network: Pharmacy networks should include all major chains to assure ease of access to claim-related medications. In addition to robust retail networks, home delivery capabilities can help to control costs and enhance utilization management. The more information available about a medication therapy regimen, the better positioned a payer is to make changes when needed, such as with misuse or abuse.
- Evidence-Based Clinical Programs: Clinical expertise and programs emphasizing global medication management are central to controlling cost and utilization of pharmacy-related claim expenses. Payers should seek programs founded in evidence-based medicine and recognized medical guidelines. The PBM’s proactive management of medication therapies involving opioid analgesics is important. Tools such as medication formularies and drug utilization review (DUR) help detect drug-to-drug interactions, duplicate therapies, inappropriate medications, excessive length of use or dosage, generic availability, and other therapeutic concerns. Intervention tools that address concerns regardless of complexity is important to ensure the injured party receives the right medication at the right time.
- Technology and Reporting Tools: An effective PBM program should enhance a payer’s claim operation. Communication portals built on redundant technology platforms that prioritize security and efficiency are imperative. Similarly, timely provisions of actionable reporting information that provide insight into program performance are critical.
When it comes to selecting the right PBM, it is important to consider cost and value. Competitive per transaction costs are as important as a proven record of accomplishment. Proficiency in delivering results should be evident, and delivered cohesively.
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