PharmAvail is an established leader within the pharmacy benefit management & consulting fields. Our professional team manages prescription benefits for employers, TPAs, governments, worker’s compensation MCOs, and HMOs with over two decades experience. Our executive team has served as consultants for several state agencies desperate to find ways of controlling drug costs without sacrificing quality within their pharmacy programs. Our services are fully integrated including a national retail and mail order pharmacy network, on-line claims processing, and extensive reporting capabilities. PharmAvail exceeds the services of our competitors with unrivaled clinical and systems expertise. Our dynamic and prospective management of pharmacy benefits sets us above the field. None of our competitors can match our superiority in member and client customer service.
Executive Summary
PharmAvail provides pharmacy benefit claims management and related services nationwide to health insurers, TPAs, independent practice associations, government plans,and self-insured employers. PharmAvail has been successful in marketing its service offerings and technology solutions to the small to medium sized healthcare plans and employer market. We assist clients, who are at financial risk for the cost of healthcare for their members or employees, to better manage their prescription drug costs and quality of care. Then under our transparent model with full-disclosure, all cost savings are passed through to the client.
PharmAvail Benefit Management was founded in 2001 by three pharmacists with extensive pharmacy benefit & formulary experience. Today the company is managed by former CEO level PBM executives, national pharmacy leaders, and directors from a major drug wholesaler. We utilize a proprietary and robust software program written onto a powerful, nationally renowned database, which is scalable, reliable and minimizes maintenance and administration costs.
We understand the importance of your pharmacy benefit plan to you and your employees. And, we take our role as a steward of your pharmaceutical care very seriously. PharmAvail offers our clients service that is solution-oriented, comprehensive and reflects your changing requirements. PharmAvail promotes and values professionalism and flexibility at every level. We implement this uniquely through our ability to customize our system to accommodate growing client needs.
Our proprietary software provides plan design options that can be implemented in a combination to ensure success for your group.
- Our extensive reporting package and capability to produce ad-hoc reporting allows us a unique instrument to determine which opportunities best fit you and your employees.
- Our experienced consulting staff will guide you every step of the way, continuously looking for ways to improve your benefit program.
- We can offer you an online tool that is available 24 hours a day, 7 days a week to view, change, track and report on real time information.
- Our elite clinical service programs collaborate to positively affect care and expenses.
- As a result of our diverse clientele we offer and continue to develop programs outside of traditional PBM services.
- On-Line / Real-Time Claims Processing
- Flexible Design w/ Cost Control Recommendations
- Comprehensive Report Catalog
- Detailed/Consolidated Billing Reports
- COB with Medical Plan/Quarterly DUR Summations
- National Pharmacy Network
- Competitive Pharmacy Contract Rates
- High Generic Substitution w/ Aggressive Pricing
- Integrated Mail Order Pharmacy
- Member/Pharmacy/Client Services Help Desk - 24/7
- Prompt ID Cards in National Standard Format
- Formulary Management/High Rebate Yields
- DSM for High Risk Disease States
- Prospective DUR for Member Safety/Plan
Efficiency
- Secure Access to Member Enrollment/Eligibility
- Systematic Pharmacy Audits/Recovery
- Strong & Experienced Clinical /DUR Team
- Board Certified Physician & Academic Advisors
- Management/Executives w/ Decades of PBM Experience
Mail Service
As a provider of a prescription drug benefit, you have undoubtedly been concerned about the escalating costs of delivering that benefit to your members. Encouraging them to rely on a mail service pharmacy - particularly for long-term medications - ranks among the most powerful means available for capturing cost savings for you and for members, while improving their overall satisfaction with your pharmacy benefit.
Our RxDirect Pharmacy Service can help you realize cost savings of up to 15% on average compared with retail networks through:
- Deeper discounts off the average wholesale price of drugs
- Fewer dispensing fees because of the extended days' supply through mail order (typically 90 days versus 30 days at retail pharmacies)
In addition, your plan can see increased savings from:
- Faster adoption of generic drugs
- Improved formulary compliance rates
- Higher compliance with utilization and safety rules
The two key mail order programs that can be used to your advantage are the Maintenance Drug Program and Over-the-counter product discounts.
Maintenance Drug Program
PharmAvail's Maintenance Program is designed for individuals using maintenance medications for the treatment of chronic or long-term conditions. Customarily health care plans allow for a maximum 90-day or 180-day supply of the maintenance medication to be dispensed at one time. The focus of this program is reduced co-payments to the health care plan member and additional savings for the health care plan. The Maintenance Drug Program is integrated with our retail network and offers experienced consultation, professional dispensing practices, timely deliveries and a proven commitment to customer service.
Most plans require patients to obtain acute care medications or first-fills of up to 30-day supply from the local network pharmacy. By using the Maintenance Drug Program a 90-day supply of medication may be obtained for a single dispensing fee that is lower than the accumulated fees charged by the local pharmacy for the same medication and same time period. The Maintenance Drug Program gives participants the convenience of larger quantities, lower prices and direct home delivery of maintenance medications. Toll-free service allows participants and the prescribing physician access to customer service representatives and registered pharmacists. Plan sponsors recognize the potential savings incurred with reduced dispensing fees and lower contract pricing.
Over-the-Counter Product Discounts
Through PharmAvail's RxDirect subsidiary members can shop online and choose from over 15,000 over-the-counter products such as health and beauty aids, vitamins, nutritional and home health care products. Other products include: non-prescription - antacids & laxatives, ear care, eye care, baby needs, deodorants, hair care, bath & body, cosmetic, skin care, vitamins, diabetic supplies, diagnostic products, first aid treatments and more. The online store offers thousands of brand name and specialty health and beauty products at competitive prices a wealth of health-related information, buying guides and other tools designed to help consumers make informed purchasing decisions. All products are shipped to the member’s door within 48 hours of receiving the order.
The PharmAvail pharmacy networks allow us to make a transformation in the quality and cost of your prescription drug benefit. Our network of 51,000 pharmacies can be narrowed to ensure a more significant cost savings to your members. You have the choice to use our open network, which guarantees access nationally to pharmacies, or to customize a network to meet your needs.
PharmAvail's pharmacy networks provide the following benefits:
- Provide you with discounted reimbursement rates
- Pharmacies that adhere to superior quality standards
- Transmit instantaneous safety messages and drug utilization review data
- Feature online claims processing that ensures each prescription is paid for at its current price and in compliance with benefit designs and contractual requirements
Concurrent Drug Utilization Review
Our claims adjudication system sends online alerts to the dispensing pharmacy about potentially serious hazards to patients before a drug is dispensed. Each drug is checked against the patient’s integrated drug history, including mail order and retail pharmacy prescriptions, to determine if clinical risks are present.
These safety edits ensure that pharmacists get focused clinical information about potential drug therapy problems before the patient receives the drug. Our Concurrent Drug Utilization Review has both standard and custom edits available.
- Drug interactions
- Inferred disease conflicts
- Therapeutic duplication
- Over utilization
- Early refill
- Appropriate age, dose and duration
- Drug cost
Disease State Management
Disease State Management is the ongoing evaluation of a diagnosed disease or infectious state, and the evaluation and implementation of appropriate therapy. A study by the Rand Corporation concluded that approximately 25% of all prescriptions were unnecessarily prescribed and approximately 30% of all prescriptions for the elderly were unnecessary. This management program includes:
- Evaluating non-drug therapy
- Use of and need for medication
- Re-evaluation of medication
- Effects of combining different medications, including Step Therapy
- Compliance with medication requirements
Our philosophy is to get the most appropriate medication to the patient. We use outcome studies to determine and maximize the cost/benefit relationship. Our client plans are managed under the premise that quality of care is foremost in our management process and cost, while important, is secondary. Additionally, we make every effort to look at the long-term results of the therapy to determine the total cost of the therapy, not just the immediate short-term cost implications.
PharmAvail uses the latest technology and reporting tools to identify all patients in a risk pool who share chronic illnesses based on:
- Ability to measure short term clinical impact of management strategies
- Ability to identify high cost-per-disease occurrence
- Ability to identify high degree of medical or pharmacological treatment variability
Care is individualized although the program focuses on the group as a whole.
Patient/Physician Education
The patient-physician relationship is fundamental to providing and receiving excellent care, the healing process and enhanced results. Many aspects of the patient-physician relationship have been subject to research by the scientific community. A substantial body of scientific literature summarizes that research and informs physicians of ways to enhance their effectiveness. For their part, patients count on an ever-growing collection of books and articles advising them how to take better care of themselves and how to interact more effectively with their doctors.
PharmAvail believes that to help positively affect the outcomes for their clients we need to assist in the education process for both physicians and patients. We provide materials directed at each specific group to help educate on the most effective course of action for the patient. The advantage of using these materials includes considerable resource savings, enhanced patient compliance, improved outcomes and increased patient satisfaction.
Retrospective Drug Utilization Review
PharmAvail's Retrospective Drug Utilization targets all prescribers involved in a potential drug therapy problem and alerts them. Alerts include a letter describing the potential problem, a complete drug history profile and a response form.
- Drug history profiles highlight potential risks and report all drugs taken by a patient, the diagnosis information if available, prescribers and dispensers by identification number and previous potential drug problems.
- Focus of alerts is informational to allow the physician to make an informed choice about drug therapy
- Between 40% and 50% of the prescribers voluntarily respond to alert letters
Case comparisons of drug utilization before and after interventions indicate 65% of the patients
have favorable changes in drug therapy. These changes can result in average drug cost savings
of $120 to $150 per case.
Step Therapy
Step Therapy is designed to insure appropriate utilization of select drugs and/or therapeutic categories. Coverage rules are created that requires that a patient receive a first-line drug before a claim can process a second line drug.
Wellness Programs
PharmAvail has developed several programs to promote wellness and member compliance. Such programs as diabetic compliance, weight loss and smoking cessation are designed to prevent or mitigate the effect of medical complications before they occur when the solution cost is less.
Diabetic Compliance
Diabetes is a multifaceted disease that effects approximately 16 million individuals in the United States. Roughly 90% of people with Diabetes fall into the Type II or non-insulin- dependent category; it ranks in the top five leading causes of death. Since diabetic patients regularly visit their local pharmacy for medications and supplies, the community pharmacy affords a great opportunity to assess the diabetic patient. PharmAvail takes this opportunity to assure and assess compliance with the most appropriate treatment program for each patient.
Weight Loss
The increasing commonness of obesity and its related health complications places a tremendous burden on health care utilization and costs. This epidemic of obesity commands prompt attention from the heath care and preventive health services in order to decrease the rise in the rate of new case of diabetes, heart disease and other obesity-related complications. PharmAvail has developed a program to help track, promote and ensure compliance and effectiveness of a weight loss program.
Smoking Cessation
An estimated 25.6 million men and 22.6 million women are smokers. These people are at higher risk of heart attack and stroke. Smoking is the leading cause of preventable death and can reduce your life expectancy by 15 to 20 years.
Under the Smoking Cessation Program, participants are offered products designed to help them stop smoking at discounted prices or free of charge. All the participant has to do is meet with a facilitator on a pre-determined timetable to maintain their eligibility in the program. When a participant meets with a facilitator, the facilitator accesses the PharmAvail eligibility file and notes them as being eligible for the time period between scheduled visits. The participant presents their ID card at the pharmacy and the claim is adjudicated through PharmAvail who, in addition to handling the financial transactions, presents a complete analysis of the program and participant compliance.
Our processing partnership with USScript affords us a steady flow of software development and continuous innovation within the IT environment. Thus our flexibility to install new client plans of any size is ensured. Unlike the larger PBMs with minimum member quotas and long installation timeframes, we can add new members quickly and economically without the high fixed cost of installation. To you this means more control over your pharmacy plan, faster response to changes in your work environment and more value for your benefit dollar.
We understand the importance of quick access to online resources in today’s health care environment, made even more challenging by direct-to-consumer drug advertising and information access through the Internet. At PharmAvail, we approach pharmacy benefit management proactively, with data-driven services that help our clients negotiate today’s health care environment economically. We act as an advocate for our clients with physicians and pharmacists, and we work to build long-term relationships with members through educational programs that encourage informed prescription drug use.
PharmAvail—Maximizing the Power of Technology
- Personalized interactive website that allows clients and members access to plan-specific information.
- Rx-Data decision support technology that transforms complex data into useful information.
- Point-of-sale claims adjudication in less than 7/10ths of a second after transmission from the pharmacy.
- Flexibility in plan design through table-driven edits that allow you to mix and match your plan’s benefits.
- Ad-hoc reports- Customized reports detailing information specific to individual issues.
- Drug Utilization & Quarterly reports- Data is used to identify adverse drug utilization patterns and also evaluate the total cost of care.
- Financial modeling- PharmAvail can suggest various ways to improve your plan’s drug lists productivity. Using “what if” scenarios, the financial impact of proposed changes in plan design can be projected using historic data.
- Online availability of reports- Through our online, real time, table-driven adjudication tool we can provide you with access to reporting that is at your finger-tips.
At PharmAvail Benefit Management, we are firmly committed to complying with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) which protects the security and privacy of patients. HIPAA has been the catalyst for many positive changes in the health care industry relative to the protection of personal, health related patient information. One of HIPAA’s primary intents was to improve the efficiency and effectiveness of the entire US health care information system. As the law evolved, it established standards and requirements governing the electronic transmission of certain “protected” health information. As a Business Associate to Providers, Health Plans and other “Covered Entities,” PharmAvail maintains HIPAA compliance as a top priority. Under no circumstance will personal health information be used or disclosed by PharmAvail for any purpose unrelated to our benefit management and claims processing functions, unless expressly authorized in advance by a member or patient.
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