Pharmacy Program

Pharmacy Program

AMC provides a Pharmacy Benefits Management (PBM) Program through its strategic partnerships. AMC’s PBM services go beyond processing prescription drug transactions by working with partners that aggressively manage drug utilization and control pharmacy spending. This is accomplished by integrating clinical expertise and advanced technological capabilities, and eliminating cost drivers while ensuring quality care while including the key advantages of electronic connectivity, allowing for:

• Quickly convert patients for future network activity
• Increase utilization and hard dollar network savings
• Adjudicate bills to fee schedule
• Pay the third party billers directly

Clinicians: Have developed a highly refined medication plan which is designed to work in conjunction with anticipated intensity of care. During the acute phase of the injury/rehabilitation process, which often is the case in a First Fill scenario, only those medications intended for treatment are permitted through the edits in our adjudication software.  This allows access for the injured worker with no out-of-pocket expense while retaining control of expected medications.

The medication plans are fully customizable to meet the unique jurisdictional needs of our Client, including –

• Access to PBM Pool
• Generic Medications
• Online/Electronic Access
• Telephone/Help Desk
• Identify PBM Usage Trends via reports
• PBM related-training

Claim professionals have the capability to authorize scripts for predetermined periods of time (or number of fills) in order to eliminate the need to perform the prior authorization process until the time is necessary or the claim status changes. Automated messaging to the claim professional occurs as prescription fill periods or quantities are nearing an end in order to allow the claim professionals to be proactive with re-setting any new authorizations for future scripts and avoid unnecessary prior authorizations when the prescription period expires.

Mail Order Pharmacy: The program AMC utilizes is a proprietary web-based Mail Order tool that is used by PBM partner to auto identify candidates qualifying for Mail Order and alert the claims professional for enrollment approval. Claims professionals can then approve or deny Mail Order transfer whereby the PBM partner Mail Order service will solicit the claimant to enroll in the program.

Out of Network Bills – This is a major concern for any Pharmacy Benefit Program when there is “leakage” by injured employees filling medications outside of the network (removing the edits we have in place) and being billed after the dispensing.

We address this through additional integrations, where all paper bills are reviewed and all Point of Sale edits are applied.  So while it is not perfect that the medications have been provided and most likely taken by the injured employee – if the edits fail – the bill is denied and no payment is issued.  This process will be key in supporting the weaning programs and enforcing the new drug formulary.

First Fill Program: Typically exchanges eligibility data with Clients daily (at a minimum), which is critical to capturing newly injured workers on the date of injury.

However, in cases where claims have not yet been reported or eligibility information is not yet available, we will incorporate a First Fill program to accommodate the initial fill process when claims have not yet been reported. This is an at-risk program whereby we can provide an initial 10-day supply of medication to a patient when eligibility has not been received. The Client would not be responsible for prescription charges from First Fills not matched to their eligibility.

The First Fill program helps direct patients to network pharmacies. Our PBM partner will provide information to the Client and/or its partners that should be passed on directly to the injured worker at the injury site. This includes providing the injured worker with a First Fill Form to take to the pharmacy. First Fill Forms are immediately deactivated ten days after the injury occurs.

Third-Party Bills:  This process is fully managed with a 100% of all prescription activity on behalf of customers, regardless of the source of the bill (i.e., Point of Service (POS), third party biller, paper, mail order, etc.). Third party bills are managed as part of our Network Optimization Program.

Generics – Working with our PBM partners, AMC incorporates generic substitution in the Business Rules for the Client’s program as described below.

Business Rules for Generics: Additional levels of formulary design can also be implemented to incorporate protocols at the point of sale thatinclude:

• Step Therapy   (i.e.,   introducing generic agents as a first-line   dispensing recommendation prior to moving towards higher priced brand drugs)
• Drug Quantity Limit Controls
• Drug Type, Category or Strength

The implementation of these types of tools can be customized to the Client’s needs (by jurisdiction, Client, etc.).

Clinical Pharmacy: A series of edits are performed when the pharmacist enters the data into their pharmacy system, which includes the detailsabout the injured worker, the prescription(s) and other pertinent information and subsequently transmits the information to our PBM partner real-time, on-line adjudication system. Checks are made for eligibility and placement of the respective drug against the formulary, aswell as comparisons against other medications on the injured worker’s patient profile. Should the submitted information trigger any of the100+ patient safety concerns within the PBM partners drug utilization program, the system sends an immediate message back to the dispensing pharmacy with a recommendation if appropriate. The PBM partner also monitors the response of the pharmacy to the onlinethrough real time web applications, and performance results are provided to Clients via reports.

Our standard edits have been developed by our Clinical staff and are proprietary in nature.

Dispute Resolution: The pharmacy we portal, assists claims professionals with decisions as they relate to claims management and the processing of pharmacy transactions. The portal has a queue for Claims Resolution, which contains paper bills that are unable to be processeddue to missing information, unmatched claimant, claim is terminated, etc.   This queue is managed by AMC’s bill reviewers.

AMC maintains a partially manual process to ensure the ability of the BR analyst to verify by reading the corresponding medical reports to confirm the services billed are actually the services provided.

Standard Reporting Package: A Web-based Reporting Tool is offered to assists customers in assessing prescription history and activity on a global or claimant specific basis. Our reporting package contains a wide array of standard pharmacy reports. In addition, customized reports can be created and made available via this web-based reporting tool. Many of the reports allow for employer level reporting. AMC’s customized workflow of the California Formulary Process Integration.

Overuse: In tandem with its PBM partner, AMC offers a concurrent alert process to the dispensing pharmacy that relies on establishedevidence-based treatment guidelines to ensure that patients receive the most therapeutically appropriate, cost-effective treatment regimen foran injury. The program utilizes an approach to guide physicians towards prescribing safe and effective, yet lower cost, alternative drugs as first-line treatment options. The program encompasses over forty medications across various therapeutic classes.

Weaning Process – This is accomplished through careful coordination between the Claims Examiner, the PBM partner and AMC’s Narcotic Nurse.  All claims prior to 1/1/18 date of injury are required to have a weaning plan in place by 4/1/18 or provide documentation from the provider to support the ongoing need for the medication at the current level being prescribed.  Through review and identification of those claimants on medications outside of the new formulary, we have developed a strategy to inform all parties of the mandated weaning plan or medical justification and are tracking the movement towards narcotic reductions.  The coordination of the Utilization Review recommendations, the Narcotic Nurse involvement and the Claims Examiner are all key to successfully reducing the abuses.​