ELMCRx’s Clinical Prior Authorization Program is a real-time clinical review of specialty and high-cost drugs Prior Authorizations (PAs) approved by a PBM. Each approval is reviewed by a clinical pharmacist for dosage, accuracy, completion of step therapies, quantity, formulary compliance, and FDA approval.
How does the Program work?
The program is essentially a “real-time audit” of high-cost claims. Our pharmacists review prescriptions before they are filled using a live connection into the PBM claims system. After each review, our pharmacist either approves or edits the prescription and enters the decision back into the PBM Prior Authorization system.
What are the Plan Sponsor Responsibilities?
The Plan Sponsor’s only involvement is to inform their PBM that ELMC Pharmacists have authority to manage the Prior Authorizations approved by the PBM. In addition, a data release form will need to be completed.
How does a Plan Sponsor pay for this service?
There are several payment options available to our clients including a choice of fee options and a combination of fee and shared savings.
What results can a plan expect?
During the past five years, the program has reduced our clients’ expense for high-cost medications by an average of 10% to 15% through direct cost savings on existing medications and cost avoidance on newly prescribed medications
How are savings determined?
Under this program, “Savings” is the difference between the cost of the medication approved by the PBM and the cost of the medication that is dispensed after our review and intervention. This method takes into account the results of any appeals that may take place.
Is there any member disruption?
Reviews take place within the time periods specified under the PBM contract. Our pharmacists work with prescribers to minimize any potential member disruption.
The program typically impacts approximately fewer than 10 members per 1,000 lives, so the potential for member disruption is small.
Can the program be implemented at anytime during the plan year?
Yes. Plan Sponsors may join at any time during the PBM contract period. All that is required is a form giving the PBM permission to release these high-cost claims for review.
For more information about how the program might work for your fund, please contact:
John Adler firstname.lastname@example.org 262-707-1076
Mary Ann Carlisle email@example.com 484-433-1412
Or visit www.elmcgroup.com/elmcrxsolutions