John Adler and ELMC RxSolutions have developed a program for eliminating cost from the pharmacy benefit management (PBM) delivery system’s ineffective management of specialty Rx Clinical Prior Authorizations.
THE VERITAS CLINICAL PA REVIEW PROGRAM FAQS
Reduce Your Fund’s Total Rx Spend by 15% without Changes or Member Disruption
what is the vertias clinical pa program?
The Veritas program is a clinical review of high cost drug Prior Authorizations (PAs) approved by a PBM. Twenty percent of the drugs costing $2,500 or more per 30-day script that are approved for dispensing by the PBM have clinical equivalents that are more reasonably priced or are more appropriate for your members.
These cases lead to a signiﬁcant increase in claims costs, as well as an increase in the incidence of speciﬁc stop loss claims and stop loss lasers. The Veritas program intervenes in real time to help prevent these situations.
HOW DOES THE PROGRAM WORK?
The Veritas program is essentially a “real-time audit” for high cost claims. Our pharmacists review prescriptions before they are ﬁlled using a live connection into the PBM’s Prior Authorization system. After review, our pharmacist either approves, modiﬁes or denies the prescription and works with the prescriber to ensure an appropriate course of treatment is received by the member.
PLAN SPONSOR RESPONSIBILITY
The Plan Sponsor’s only involvement is to inform their PBM that ELMC Pharmacists have ﬁnal approval authority for PAs approved by the PBM.
IS THERE ANY FINANCIAL RESPONSIBILITY FOR THE PLAN? No.
ELMC’s fee is a percent of the savings achieved.
Savings are determined by taking the annual cost diﬀerences between the PBM approved drug and the ELMC approved drug dispensed to members. The shared savings fee is then divided by twelve and billed monthly. Claims are downloaded from the PBM monthly. If the drug on which the savings are based is no longer being utilized, we stop billing for the savings.
WHAT RESULTS CAN A PLAN EXPECT?
Over the past four years of conducting these reviews for 60,000 covered members, the Veritas Program has reduced clients’ annual pharmacy spend 15% to 20%, through direct cost savings on existing medications and cost avoidance on newly prescribed medications.
THESE ARE THE KEY PROGRAM CHARACTERISTICS:
We initially edit approximately 20% of the PBM approved PAs
Our final edit rate is between 10-12 PAs per 1,000 member lives (covered members ans dependents)
These few edits on average generate a 15% reduction in total Rx spend net-net.No changes. No mamber disruption.
IS THERE ANY MEMBER DISRUPTION? No.
Reviews take place within the time periods speciﬁed under the PBM contract and our pharmacists work with
prescribers to minimize any potential member disruption.
In addition, because the Veritas Program only impacts 10-12 members per 1,000 lives, the opportunity for any potential member disruption is minor.
ARE ANY CHANGES NEEDED TO PUT THE VERITAS PROGRAM IN PLACE? No.
The program requires:
No plan design changes or formulary changes No SPD changes
No change in the current PBM unless they won’t provide access to their Clinical PA system
No change in current medical or pharmacy beneﬁt consultants
CAN THE PROGRAM BE IMPLEMENTED AT ANY TIME DURING THE PLAN YEAR? Yes.
HOW ARE SAVINGS DETERMINED?
Savings is the cost diﬀerence between the Rx initially approved by the PBM and the cost of the Rx that is dispensed after our review and intervention. This method considers the results of any appeals.
For example, if the PBM approves a drug that costs $10,000 per month and our review determines that a $6,000 per month drug is clinically appropriate, the savings (or cost avoided) is $4,000 per month or $48,000 per year if the member remains on the plan and continues to take that drug.
PROOF OF SAVINGS
As proof of savings, we take a screen shot of all PBM approved medications. This becomes part of the claims’ history ﬁle and is available on request.
VERITAS FEES ARE BILLED MONTHLY BASED ON ACHIEVED SAVINGS
For example, $48,000 Total Savings x 25% = $12,000 in annual ELMC compensation. The shared savings savings fee scale reduces each year, for any script starting at 25% year 1, 20% year 2 and 15% year 3.
Monthly billing is calculated at $12,000/12 months= $1,000/month per month for this specific script
We monitor the claimant's eligibility ans use of the drug each month. if the claimant leaves the plan or discontinues the drug, we will not bill for the savings.