Problem
For a small to mid-size plan sponsor, prescription drug plans can feel overwhelming. That is why it is important to partner with a pharmacy benefit manager (PBM) who provides the personal attention, clinical support and customer service they need to properly implement and control their pharmacy program.
When one of our small (200 lives) groups reached out to us for support regarding an issue with a prior authorization (PA) request for one of its members, our dedicated servicing teams jumped into action.
Client Overview
Industry: Property Management
Group Size: 200
Plan Type: Self-Funded, Prescription Drug Plan
Solution
PBD’s account management and client support teams got to work immediately once they were made aware of the issue. When the member was having issues receiving PA approval for her medication, one of our client support representatives faxed an urgent PA request to the member’s doctor. When the PA was not received, our representative was not content with simply allowing this PA to be forgotten. The next course of action was to receive approval from PBD’s Prior Authorization team to extend the previous PA request that was on file. Once completed, our client support representative contacted the member’s pharmacy directly and helped them put the claim through successfully on behalf of the member.
After going through the appropriate steps for the member, our customer support representative contacted the member’s physician once again to confirm the prior authorization was successfully completed. However, this was not the end of the story.
That is when the member’s physician indicated they wanted the member to try a different medication prior to signing off on the requested PA. Not fazed by the quick and fluid nature of the chain of events, our representative called the member’s pharmacy to cancel the old prescription and deactivate the override on the previous PA that was extended as part of the initial resolution. The new medication was less expensive for the group, but still a Tier 4 $60 copay for the member.
In addition to the persistent and dedicated work of the client support representative, our account management team also stepped in to offer added value for both the plan sponsor and member by quickly identifying a generic equivalent of the new medication the physician requested the member use.
The generic drug, which was a Tier 1 product on our formulary, had the same drug efficacy, but cost less and did not require a prior authorization for the member to obtain.
Results
What could have been a stressful incident for both our group and the member turned out to be a win-win situation for all involved. With a dedicated client support team in place, PBD was able to work with the group, the member, the pharmacy and the physician’s office to resolve a cumbersome and complicated process.
In addition, PBD’s formulary structure helped the group and the member save money. If the member remained on the initial medication, there would have been a $60 copay for the member — a Tier 4 copay with a prior authorization — and a group cost of $1,240. In addition, if the member had been prescribed the new medication by the physician – a Tier 4 medication with a PA – there would have been a $60 copay for the member and a $625 cost for the group.
In contrast, the member was placed on a generic equivalent and now pays a $10 copay for a Tier 1 drug with no PA. The group also benefited from PBD's formulary management practices by our team of expert pharmacists by only having a cost of $11.40.
At Pharmacy Benefit Dimensions, we deliver the solutions that not only maximize your cost savings, but exceed customer expectations through our exceptional service. Because of our quality service, our groups can focus on their ongoing pharmacy program while providing more value and satisfaction to the members we serve.