36. What is your approach to the process for managing prescription drug costs? • Managing prescription drug cost is significantly dependent on your current funding arrangement. o Fully insured While there are many positives to being fully insured you are ultimately at the mercy of the insurance carriers in regards to your contracts and Rx spend. Typically, drug formularies that are offered by the BUCA’s (BlueCross, United, Cigna, and Aetna) are significantly limited. • Rarely do you see RX claims denied unless it is experimental or specialty. o In the event a drug is denied we will work with the carrier to get the medication approved. • How does this happen? o Providing proper documentation form the provider that the Rx is medically necessary. o Documentation that a generic or brand name does not provide the same medical effectiveness. o Self-insured If you are self-insured (not level-funded) you will be working directly with a PBM who will manage your formulary and provide details in regards to your Rx spend. Under this platform the broker and client would take on a larger responsibility to manage the RX cost.
• Rebates • AWP’s • Carve outs • Outsourcing • Copay assistance
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