TPA & BROKER
INFORMATION
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Complete Set of
TPA-Broker Handouts (from all sections below)
An
Overview
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HERE
for Overview
Handout
Northwest
Pharmacy Services (NWPS) is a full service, non-profit, Pharmacy Benefit
Manager (PBM). We were founded in 1985 and today serve members in all 50
states. Prescription drugs continue to represent one of the fastest
growing segments of health care expenditures. NWPS works with the pharmacist, the health plan or client, and the
plan member to help reduce costs and improve quality by sharing timely
information so they can all benefit.
Our Points of
Distinction:
Leadership in Technology
We help our
clients turn data into information they can use. Our data management
system can integrate pharmacy and medical data, allowing our clients
maximum flexibility for data input/output. Sophisticated economic
modeling capability can assist in critical decision-making by
identifying quality and cost savings opportunities. We make quarterly
recommendations outlining both quality and cost saving opportunities for
our clients.
Clinical Excellence
By providing timely, customized information, we help our clients
implement clinical, drug utilization review and disease management
initiatives based on current best practices and evidence-based medicine.
Financial Transparency
We believe in a transparent approach to drug benefit management with no
undisclosed revenue streams. We subscribe to full disclosure in our
business practices and our relationships with our clients.
Cost Effectiveness
Our evidence-based formulary is designed to provide the lowest pharmacy
cost per member per month. Formulary decisions are payer and member
focused. We offer members a prescription price inquiry system to help
determine the best price for their individual needs.
Customer Service
Northwest Pharmacy
Service staff members make sure clients and plan members receive an
immediate answer and support when requested. We have a toll-free help
desk staffed by experienced pharmacy technicians who have a solid
working knowledge of the clients’ plan design including drug coverage.
Our licensed pharmacists are available for clinical questions from
either providers or patients and also support our help desk.
Pharmacy
Network
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Pharmacy Network
Handout
Northwest Pharmacy Services contracts with more than 850 pharmacies
within the State of Washington and more than 55,000 pharmacies
throughout the United States. This broad network enables us to negotiate
discount rates on behalf of our clients and obtain convenient,
professional pharmacy services for members. Service makes a
difference, and our members will receive quality service with our
pharmacy network. For most members, the experience at the pharmacy
represents their opinion and satisfaction with their prescription
benefit.
· Our
state-of-the-art claims adjudication technology provides immediate
and accurate claims processing.
· It
ensures each prescription is paid for at its current price and in
compliance with the benefit design.
· Our
system allows for extensive messaging to pharmacists regarding
eligibility, formulary issues, and clinical information to protect
members from unsafe drug therapy.
Data Management
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Data Management
Handout
Northwest
Pharmacy Services (NWPS) provides the right information for
clients to manage their pharmacy benefit program by
providing customized reports that include detailed data. Our
reporting has built-in flexibility to assist in addressing
the rapid changes in the healthcare industry and the dynamic
managed care environment. Clients praise our standard report
package, which includes reports on financial and utilization
indicators, specific drug utilization by therapeutic class,
pharmacological classification, and provider performance.
Claims Data Analysis
NWPS has
developed the expertise in the use of medical and pharmacy
claims data to assess utilization and the financial impact
of alternative treatment options. We draw upon our in-depth
knowledge of pharmacy, medical and economic data sources.
Our experience in developing health economic and
epidemiological models helps clients achieve long-term
competitive advantage through research-based solutions to
complex business problems.
Predictive Modeling Studies
Models have
become an important tool to aid today’s decision makers, but
to be effective; a model must address relevant outcomes in a
credible, flexible understandable way. NWPS meets this goal
through solid research, innovation, use of advanced modeling
techniques and sound cost estimates based on large
databases. Our predictive modeling programs can benefit any
organization responsible for paying or arranging care.
Claims
Management
Northwest Pharmacy Services claims
management adjudication system helps clients:
· Increase
generic utilization
· Improve
formulary compliance
· Foster appropriate use of medications
Point of
Service
Northwest Pharmacy Services delivers a
sophisticated point-of-service processing system with real-time
information to manage claims within the client’s plan guidelines.
Online
Concurrent Drug Utilization Review
Our online claims processing system
provides sophisticated concurrent drug utilization review (DUR) to
ensure safe drug usage. The system evaluates the appropriateness of the
medication at the point-of-sale by checking for:
|
· Drug-drug
interactions
· Incompatibilities
· Appropriate
Dosage |
· Therapeutic
Duplications
· Refill
Frequency |
Formulary
Management
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Formulary Management
Handout
Prospective Review
Information
produced by Northwest Pharmacy Services Clinical Management Team during
retrospective reviews is analyzed for trends and patterns common among a
population of members. With this information, policy recommendations are
made to the client regarding member education, benefit design or other
interventions to improve future program value. Through this method of
utilization analysis, NWPS is able to identify for clients the
underlying causes that contribute to the significant increases in drug
plan costs. We center our prospective analysis on the following key
factors:
· Patient
Consumption Habits:
To
determine potential over utilization or abuse.
· Physician
Prescribing Habits: To
reveal physician-prescribing practices, which increase drug plan
costs.
· Pharmacy
Dispensing Habits: To
uncover low generic dispensing and other practices, which increase
drug plan costs.
· Overall
Drug Use Patterns: To
aid clients in achieving target drug use goals.
Retrospective Review
All clients have the option
of utilizing the Northwest Pharmacy Services Clinical Management Team to
perform formal retrospective review. The team reviews the utilization
review reports produced by the NWPS claims processing center. The
reports, compiled by NWPS, focus on high utilizers of drugs and
providers to identify a group of patients who may be characterized as
poly-pharmacy users. These patients are not always users of large
numbers of different drugs, but they may frequent multiple physicians
and pharmacies. Specific audit report criteria include:
· Total prescriptions for the
quarter greater than or equal to X,
· Average prescription cost per
quarter greater than or equal to $X.XX,
· Total controlled substance
prescriptions per quarter greater than or equal to X,
· Prescribers accessed each
quarter greater than or equal to X,
· Pharmacies accessed each quarter
greater than or equal to X, and
· At least X different
prescriptions in the same therapeutic class.
It is important to identify these
patients quickly as they are particularly vulnerable to unnecessary use
of medical care services. Furthermore, uncoordinated care in these cases
can lead to drug/drug interactions, therapeutic duplications,
inappropriate drug consumption, or compliance problems. Real time
communication with clients, members, physicians, or our pharmacy
network, may be facilitated through our toll-free help desk. Our help
desk staff consists of experienced pharmacy technicians who have access
to real-time claims processing data and plan specifications. Our
licensed pharmacists interact with our help desk personnel to resolve
medication related issues, e.g. drug interactions and prior
authorizations.
NWPS has documented
significant cost savings to the client and improved care for the members
from these clinical efforts by improving adherence to treatment and
avoiding unnecessary utilization of high cost pharmaceuticals.
Clinical Management
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HERE
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Clinical Management
Handout
Our
professional Clinical Management Team is comprised of a highly qualified panel of
pharmacy providers, pharmacy educators, medically trained consultants
and staff to support the clinical, drug utilization review and disease
management initiatives of our clients.
Our Help
Desk
In contrast
to many Pharmacy Benefit Managers (PBMs), our Help Desk is
local, and is staffed only by experienced pharmacy
technicians with Registered Pharmacist backup. They respond
promptly to all calls, and have a well-deserved reputation
as being friendly and helpful.
We
provide the following
optional services for our clients:
· Policies
and procedures for the concurrent and prospective drug utilization.
Comprehensive retrospective drug utilization review program, targeting
over and under utilization trends within specific therapeutic class
categories for members.
· Contacts
with physicians, pharmacists and patients when clinically-relevant
concerns are identified.
Acted upon cases are re-reviewed to determine impact on cost and
quality.
· Specialty
pharmacy provider contracting for access to injectable medications
whether for self-administration or for medical provider administration.
Specialty pharmacy services include patient support and counseling
at no extra cost to the payer.
· Condition
management through an Internet-based medical decision support program.
This service utilizes a 24/7-nurse help line, a personal educational
resource for medically related questions, monthly health management
newsletters and a health risk assessment.
Medication Therapy Management
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HERE
for Medication Therapy Management Handout
What is medication therapy
management?
· A
program designed to help patients get even greater value
from their medications by reducing medication waste.
· Targets
patients with chronic illnesses and/or using multiple
medications.
· Free,
voluntary service to patients.
What is
medications waste?
Waste occurs whenever…
· A
high cost medication is used when an equally effective
lower cost alternative is available.
· A
patient requires a different mediation due to a side
effect or reaction to a medication
· A
medication fails to achieve intended results.
· A
Patient is non-compliant with his or her medication.
How do
we address medication waste?
Our Medication Therapy Quality Review programs offer 1:1
counseling with trained pharmacist to help patients
understand the medications they are taking and how the drugs
work.
1. Drug
problem review of prescriptions at the time of dispensing.
This service goes beyond what pharmacists ordinarily do
when dispensing medications. Pharmacists contact the
patients physician to resolve potential drug problems before
the prescription is dispensed, and in some cases to change a
drug to one that is more cost-effective for the patient. The
review is done in real-time before the prescription is
dispensed. We offer this service through a service partner: Outcomes
Pharmaceutical Care.
Pharmacists are compensated only when they identify,
document and resolve a drug related problem. This firm
guarantees that the estimated costs avoided from resolving
drug therapy problems will be greater than the premiums they
charge. This service can easily be designed to emulate the
service being offered to King County employees (>25,000
covered lives).
2. Comprehensive
review of patients’ drug therapy.
The service involves making a sit-down appointment with
a qualified pharmacist to go over the patient’s medication
issues. Sometimes called a Comprehensive Medication Review
or ‘Brown Bag Review”, this service is typically offered as
a voluntary service to patients. Patients are directed to
one or more pharmacies close to their home.
Patients are not required to have their prescriptions filled
at this pharmacy. Studies have shown that patients using
such services have positive outcomes in terms of disease
control, lower medical care costs to the plan, and are
highly satisfied with the service. (references available
upon request)
Targeted Patient Drug Review
Review of patients with complicated
and/or costly drug therapy
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HERE for
Targeted Patient Drug Review Handout
What
does a targeted review involve, and why do it?
Our service involves reviewing
Rx drug claims according to pre-determined criteria to
identify patients having a high probability of suboptimal
drug therapy due to patterns of high drug use, high cost, or
use of drugs with a high risk potential. We always do so in
a manner that masks patient identity or preserves patient
confidentiality. It is usually the case that a relatively
small number of patients account for the highest use of
services and are the costliest to the health plan. When
examined more closely, we often find opportunities to
simplify drug regimens or to use lower cost drugs.
Targeting patients in this
manner is the most cost-effective way to provide savings to
employer or insurer and to the patient. Under Medicare Part
D for senior citizens, this service is called medication
therapy management, and is a required service. We
believe the same process can benefit patients less than 65
years of age.
How is
the review conducted?
Once our drug use review service
identifies cases for possible follow-up, it is up to the
client or health plan to determine the next steps. If the
client wishes, we offer a Comprehensive Medication Review
Service that involves having a qualified pharmacist
review the patient case. Many times the patient’s regular
pharmacist can provide this service. If not, we refer the
case to an in-state drug therapy expert.
The service is voluntary. First,
the pharmacist contacts the patient and, with permission,
conducts either a phone interview or face-to-face meeting to
gather data about all current medications, including OTCs,
herbals and vitamin supplements, and the reasons for taking
them. Next, the pharmacist reviews the list for potential
drug therapy problems or opportunities to decrease costs,
and contacts the patient’s doctor with recommendations. The
pharmacist then follows up with the patient and the
dispensing pharmacy (if different).
Many times patients don’t fully
understand their disease or how drug therapy works for them.
We often find that the most effective interventions involve
explaining drug therapy to patients to encourage better drug
taking compliance, and teaching or reinforcing
self-management and self-monitoring skills.
What are
the benefits?
Studies show that service
initiated changes in drug therapy reduce drug and/or medical
care costs.
Secondly, patients are usually
highly satisfied with the service, especially when they feel
there is insufficient time to fully discuss these matters
with their regular physician or pharmacist.
