1 january 5, 2014 ©copyright 2010 jacqueline madrigal benefits manager
TRANSCRIPT
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Jacqueline MadrigalBenefits Manager
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Self Funding
Allows An Employer The Advantage
Of Forecasting Claims
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Understanding
Your
Population(Being Plugged In)
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Know The Demographics
Of Your Employees:
EthnicityGeneration within the United States
Age RangeLevel of Education
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Case Study
Specialty
Moving Lupron®
Lupron® per claim costs dropped 60% by moving to prescription benefit
Prescription Benefit Results:
Lupron originally billed through physicians office at cost of $3,000 per claim
Partners Rx moved Lupron to prescription benefit, saving $1,800 per claim
Lupron® costs: Prescription benefit
$1,200
Lupron® costs: Medical benefit
$3,000
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Case Study
Over The Counter
Tier Zero benefit
Ulcer medication per claim costs dropped 87% by moving to Tier Zero OTC prescription benefit
Prescription Benefit Results:
Ulcer medications originally billed at cost of $165 avg per claim
Partners Rx implemented Tier Zero prescription benefit, saving $143 per claim
Ulcer medication per claim avg. costs after moving to
Tier Zero benefit
$22
Typical ulcer medication costs per claim avg.
$165
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“My goal… Minimizing my exposure, by understanding my population.”
Jacqueline Madrigal, Benefits ManagerAmerican Apparel
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Being Connected(Insight)
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American Apparel Medical Plan Benefits
Covered Services
EPO PPO
In- Network Out-of-Network
SUMMARY OF SERVICES
Physician Visit $10 copay $15 copay 30%
Specialist Visit $10 copay $15 copay 30%
Diagnostic Tests no charge 10% 30%
Laboratory and X-Ray Services no charge $15 copay 30%
Inpatient Hospitalization no charge 10% 30%
Outpatient Surgery $10 copay 10% 30%
Emergency Room Visit $100.00 $100.00 $100.00
Urgent Care Visit $10 copay $15 copay 30%
Ambulance Services $50 copay 10% 10%
Wellness Benefits no charge $15 copay No Coverage
PRESCRIPTION DRUGS
Generic $10 copay $10 copay No Coverage
Preferred Brand $25 copay $25 copay No Coverage
Non-Preferred Brand $40 copay $40 copay No Coverage
Mail Order 2x copay 2x copay No Coverage
This is only an outline of benefits please see the Benefits Summary for a complete description of coverage.
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Food Vendor
s
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How Do I Measure Success?
Generics 78%Running Below ExpectedHealthier and Happier Workforce
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Comprehensive Clinical ApproachImproving Member Care
Reduce Gaps in Care
Provide Relevant Education
Improve Adherence
Maximize Safety
Targeted patient-specific reports and education to prescribers and members:
• ACEI/ARB use
• Statin therapy
• Asthma management
• Migraine prevention
Prescriber Outreaches:
• Educational information
• Leading industry guidelines
Member Outreaches:
• Insightful information on general health topics: pain, sleep, allergy, cholesterol management, appropriate antibiotic use and maximizing generic utilization
Prescriber Outreaches:
• Drug Interaction Alert Program
• Geriatric Monitor Program
• Narcotic Drug Utilization Review Program
Prescriber Outreaches:
• Targeted educational mailings on such topics as depression and cholesterol disorders
Member Outreaches:
• Targeted educational mailings on the importance of medication compliance
• Phone call reminders for late refills
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- Prior Authorization- Step Therapy Edit- Clinical
Outreaches – Provider & Member
- Quantity Limit Program- Dose Optimization
Program
- Brand to Generics Program - Formulary Management- Provider & Member Education
- Low Total Cost Formulary
- Generic Strategies- Network/MAC- Rebates
Result: Lower Ingredient Cost Per Day
Targeted Management ProgramsUtilization Quantity Per Rx New Drug MixCost Per Unit
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Additional Helpful Hints
1. TPA - Weekly or Bi-Weekly Claims Run2. TPA - Request Mid-Week Claims Run: i.e. Receive report on
Wednesday and Fund the following Tuesday 3. TPA -Strong working relationship with Case Manager /Nurse
Manager 4. Request from PBM-Quarterly Reports:
1. Top 100 Drugs by Use and by Total Rx2. Top 100 Drugs by Use and Amt Paid
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Q & A