1 January 5, 2014 ©Copyright 2010 Jacqueline Madrigal Benefits Manager.

1April 10, 2023©Copyright 2010

Jacqueline MadrigalBenefits Manager








Self Funding

Allows An Employer The Advantage

Of Forecasting Claims


Understanding

Your

Population(Being Plugged In)


Know The Demographics

Of Your Employees:

EthnicityGeneration within the United States

Age RangeLevel of Education










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


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


“My goal… Minimizing my exposure, by understanding my population.”

Jacqueline Madrigal, Benefits ManagerAmerican Apparel


Being Connected(Insight)


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.


Food Vendor

s


How Do I Measure Success?

Generics 78%Running Below ExpectedHealthier and Happier Workforce


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


• Drug Interaction Alert Program

• Geriatric Monitor Program

• Narcotic Drug Utilization Review Program


• 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


- 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



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


Q & A

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