When an employer retains Regional Care to manage its health benefit claims we are being trusted with a significant budget item.  As such, we are committed to ensuring that each claim is subject to several controls, including: the edits,

security and automation in our system; an experienced staff with appropriate levels of authority in what they are able to adjudicate; and partnerships with specialty firms that maximize cost control opportunities.

Regional Care’s Pharmacy Benefit Management (PBM) relationships are committed to a balanced approach which emphasizes low net cost while promoting cost-effective, clinically efficacious drug utilization.  This commitment is reflected in our focus as an organization to shun the “black box” of the traditional PBM industry and make our contracts with our clients completely transparent.

Transparency

“Payors and patients have the right to know what is going on with their benefit both financially and clinically”                    - Center for Health Transformation

We are committed to absolute integrity in every aspect of our business.  From the start, we knew that the right way to do business was to work with PBMs that completely disclose all of our sources of their revenue.  This includes the following components found in all Regional Care PBM contracts:

	A guarantee of manufacturer’s rebates, but also sharing of actual amounts gained above the guarantees;
	Full disclosure of all income from manufacturers;
	Elimination of the possibility that contracts with clients will become obsolete and non-competitive by applying a “best of market” price assurance;
	All our reporting is completed at the most detailed level of coding so pricing on individual drug transactions cannot be obscured;
	Full disclose all MAC lists for generic drugs throughout the contract; and
	Utilization of single source of AWP pricing so that program performance can be consistently measured and referenced.

Management Reporting and Analysis

Another component of an effective PBM relationship is gaining an understanding of cost drivers and applying the clinical cost management programs to mitigate those drivers.  As a result, our relationships have two important features.  The first is inclusion of a Clinical Pharmacist to the Account Management Team.  These individuals have significant experience in working with group health plans and strong analytical skills.  They complete at least an annual review for each of our clients and analyze critical areas such as therapeutic classes, top dispensed products, clinical indicators and prescriber statistics.  Key trends will be identified and action plans routinely recommended for improving benefit plan performance.  The action plans will be supported by modeling of financial impact.

The second step is use of a comprehensive set of analytical and reporting tools.  These include:

	Online Reports: Provides access to over 50 standard financial, billing and utilization reports that have been previously built for our client base.
	Ad Hoc Reports: Provides nearly unlimited viewing of claim, participant, physician and drug utilization.
	Pharmacist-Based Reports: Produced by our clinical pharmacist, these reports include trended and benchmarked utilization statistics with an Executive Summary detailing key changes in the program. Graphics are included, as well as recommendations for improved performance.

Clinical Programs

Our PBMs take their role of improving quality, monitoring safety and managing health care costs very seriously, and have developed several programs that are available through the guidance of your Account Management Team.  Following are descriptions of these programs:

	Concurrent Drug Utilization Review:    PBM systems warn pharmacists of the potential harm involved in dispensing particular medications.  The edits are consistent with NCPDP standards.  An example is the prescribing of two different medications by two different providers that can cause harm or limit the effectiveness of either medication.  Other examples are a warning against a refill that has occurred too soon and a prescription where the dose is higher or lower than recommended by the manufacturer.
	Quantity Limitations: The clinical pharmacist constantly monitors information provided by manufacturers and physician groups related to the appropriate dosage of drugs and the frequency of taking drugs. Some drugs are not designed to be taken on a daily basis, and should not be prescribed as such. The system will send a message to the pharmacist informing them if the number of doses or the frequency is greater than protocol established by the manufacturer.
	Clinical Prior Authorization: In certain cases, there may be a question on whether a prescribed drug therapy meets the medical necessity definition in your Summary Plan Description. Similar to the advance approval or pre-certification of a hospital admission, these therapies require that the prescribing doctor contact the PBM to review the condition and the medical necessity of taking the drug.
	Step Therapy: Within specific therapeutic classes, multiple drugs may be available to treat the same condition. When there is a significant difference in the cost of the drugs, a Step Therapy program requires that the doctor try the lower cost drug prior to prescribing the higher cost drug. In many cases this will involve prescribing a generic alternative before a name brand is prescribed.
	Clinical Interventions: Prescriptions that have been filled should be viewed as an ongoing opportunity to improve quality and reduce your costs. The PBM’s analytical tools and pharmacists identify individuals where improvements in quality and cost can occur. Once identified, letters are sent noting the area for improvement and the recommendation.