Clinical Services

RxAdvance’s staff of experienced pharmacists and care managers provide plan sponsors with clinically-driven services focused on safety, efficacy, and cost containment. Using Collaborative PBM Cloud™ RxAdvance plan sponsors will receive value-added clinical analyses, reporting, and recommendations that will improve clinical outcomes while controlling costs.

Our innovative and distinctive clinical services include:

Medication Therapy Management

Due to PBMs’ inability to conduct impactful MTM services, plan sponsors are forced to outsource MTM to vendors whose tools are labor-intensive, semi-automated, and standalone. As a result of this ineffective outsourcing, plan sponsor staff, pharmacists, and prescribers are unable to work collaboratively to produce low-cost and high-quality MTM outcomes.

To address these critical deficiencies, AdvanceMTM through IntelligentDUR360°Gateway™ delivers a fully integrated MTM solution

  • Fully configurable with automated patient identification, enrollment, and notification that processes in real-time and alerts prescriber at the Point of Care
  • Every time a prescriber prescribes a new medication, AdvanceMTM™ dynamically analyzes a range of factors, including cost, prescriptions, diseases, additionally configured criteria, and newly prescribed medication to determine the MTM eligibility of the patient. If the patient is MTM eligible, AdvanceMTM™ alerts the prescriber to complete the comprehensive medication review (CMR)
  • The CMR is pre-populated with prescription history, which streamlines the workflow for the prescriber,enabling easy entry of OTC and non-PBM recorded medications
  • The Patient-Rx360°™ prescription listing is then overlaid against patient medical claims and disease conditions, populating the following alerts:
Generic substitution Therapeutic appropriateness
Inappropriate duration of drug treatment Medication adherence
Clinical abuse and misuse Drug-disease interactions
High or low dosages Drug-drug interactions
Over and under utilization CMR
Drug-gender precautions Drug allergies
Drug-pregnancy precautions Drug-age precautions
  • A new Patient Medication Listing (PML) and a Medication Action Plan (MAP) is automatically generated for patient consultation
  • After successful CMR, a compensation payment is queued up automatically pending patient confirmation of CMR completion through smart mobile device. This CMR process is completed in less than 15 minutes

Medication Adherence Management

Patient non-adherence and medication errors cause 125,000 deaths per year and place a considerable financial burden on the nation’s healthcare system. This burden is estimated to be $290B annually, according to the New England Healthcare Institute. RxAdvance believes it is the responsibility of PBMs to not only dispense appropriate medication but also enhance patients’ adherence. If PBMs proactively engage all care stakeholders, it will not only reduce the financial burden on plan sponsors but also generate better health outcomes for the patient.

Academic researchers and industry experts agree that medication adherence alone cannot reduce the drug-impacted medical costs for plan sponsors. RxAdvance clinicians concur that the true solution requires a comprehensive three-pronged approach.

AdvanceMAM is a fully automated, comprehensive medication adherence management solution that engages patients, prescribers, pharmacists, and caretakers at every touch point in the care continuum.

1. Identify and enroll: Prescriber-led and pharmacist-assisted CMR is used to eliminate ineffective medications

  • At Point of Care, during a refill/new prescription, system alerts prescribers with adherence-related information that prompts a physician to conduct a comprehensive medication review (CMR). This system-generated medication review identifies and eliminates medications for which adverse drug events outweigh the benefits and are ineffective for the patient’s overall quality of life. After identifying the right prescription regimen, the patient is recommended to a health plan-sponsored adherence-monitoring program. At that point, the enrolled patient information is directly pushed into the RxAdvance patient advisory team workflow, which allows RxAdvance to monitor and facilitate patient intervention/outreach (through qualified advisors) using system-generated alerts
  • At Point of Sale, if for some reason the patient is not identified at Point of Care, then the pharmacist will be alerted to engage the patient to conduct a CMR and can also recommend the patient to an adherence program

2. Aggregate, organize, and deliver: AdvanceMAM aggregates, organizes, and delivers medications through a disposable pill tray that is implemented in two stages

  • Outreach and educate: During this stage, RxAdvance advisors proactively reach out to recommended/qualified patient, explain the program, and enroll/on-board the patient
  • Install and dispense: During this stage, an electronic patent-pending PillStation is shipped to and installed at the patient’s residence. This device is fully integrated with and wirelessly connected to Collaborative PBM Cloud™. In real-time, it collects, consolidates, and transmits member’s adherence and vital-signs data to RxAdvance. After installation, RxAdvance aggregates and delivers all medications to the patient’s home on a weekly or bi-weekly basis from a centralized location using prefilled disposable pill trays. This unique differentiator of the AdvanceMAM program reduces ADEs, improves medication organization, and increases adherence and convenience

3. Monitor and Report: AdvanceMAM monitors and follows up efficiently with all care stakeholders

On an ongoing basis, Collaborative PBM Cloud™ monitors patient adherence and automatically generates alerts that are tracked by care advisors who reach out to non-adherent patients. Another distinct feature of AdvanceMAM is the ability of RxAdvance advisors to build a social connection with the patients and collect vital information about their well-being.

AdvanceMAM™ also automatically identifies member adherence gaps and alerts members and their caretakers through a mobile device. For a typical Medicare plan, RxAdvance recommends the following level of monitoring:

% Of Members
System Driven Monitoring
Degree of Personal Involvement
Auto reminders and alerts – No personnel involvement

These recommendations and the member distribution can vary by line of business, patient demographics, and plan sponsor goals. AdvanceMAM collaborates with plan sponsors to conduct data analysis to recommend the appropriate adherence program.

Patient adherence activity, which is part of Patient-Rx360°™, is pushed real time into the workflow of clinical/pharmacy staff of plan sponsor using IntelligentDUR 360°Gateway™ and becomes part of a patient’s registry. This also helps clinical/pharmacy staff of the plan sponsor to take corrective action towards those patients who are enrolled but not adherent. In addition, vital information that was collected during the outreach by an advisor is aggregated and shared with the clinical/pharmacy staff of the plan sponsor, which can help plan sponsors identify precursors to major health events (emergency visits) as part of each patient’s case/care management.

“No doctor ever really knows if their patients are getting their medication filled except by patient self-reporting. Actionable information at the point of care for the provider is essential for the best patient care and for the important Medicare Advantage Star Medication Adherence outcome measures. Finally, someone in the PBM industry has realized the doctor must be given actionable information at the point of care to be able to prescribe intelligently. This should be the standard of care.”

George Rapier III, MD
Chairman and CEO
WellMed Medical Management Inc.,
120K Member Medicare Risk Organization

Coverage Gap Prediction & Prescription Planning Services

It is the PBM’s responsibility to predict which patients are approaching the coverage gap and proactively work with plan sponsors, prescribers, and patients to build an effective and alternative prescription plan to mitigate the impact of the benefit gap.

To address this critical need in the market, RxAdvance launched AdvanceCGP³™, a solution that facilitates dynamic coverage gap determination modeling and offers a prescription planning capability.

  • IntelligentDUR 360°Gateway™ automatically generates a list of patients who will approach the coverage gap by using prior-year pharmacy claims data and patient-specific disease conditions
  • Post identification, the system generates a therapeutic alternative path that eliminates/extends the coverage gap and proactively encourages members to engage the prescriber
  • During the subsequent patient visit with the physician, IntelligentDUR 360°Gateway™ alerts the physician about coverage gap alternatives available to the patient and enables the physician to select an alternative prescription regimen to mitigate the impact of the coverage gap and increase adherence
  • IntelligentDUR 360°Gateway™ proactively informs clinical/pharmacy staff of RxAdvance and plan sponsor about patients and prescribers who are ignoring coverage gap system alerts and generates outreach communication alerts
  • IntelligentDUR 360°Gateway™ also notifies clinical/pharmacy staff of plan sponsor about patients who have traditionally been adherent and who will stop taking medication due to their coverage gap even after adopting a suggested alternative path. This empowers the plan sponsors to compare medical costs due to non-adherence with coverage gap medication costs and thus allows plan sponsors to make more thoughtful business decisions geared toward creating better health outcomes

Specialty Management Services

Specialty pharmaceuticals have contributed substantially to the rise in the nation’s drug costs over the last several years, and these costs are projected to increase by more than 65% by the end of 2015. In addition, whether a drug is covered under the medical or the pharmacy benefit can lead to substantial variation in management. The prevalent “buy & bill” model is unmanaged and expensive, and needs to be replaced with an “authorize & manage” model. The RxAdvance solution to this growing problem is its full-service process for specialty management, supported by the RxAdvance Collaborative PBM Cloud™.

AdvanceSpecialty management includes the following five services:

  1. Prior authorization (PA) management: RxAdvance delivers a collaborative, rule-based, and user-configurable PA system that leverages all data sources. This enables determination of clinical/medical necessity, prescriber utilization, and prescribing patterns
  2. Utilization management: The system ensures that requested drugs meet P&T guidelines (quantity limits, route of administration, and place of administration) by leveraging industry guidelines/ADE indications and delivers this information at Point of Care and Point of Sale through IntelligentDUR360°Gateway™
  3. Procurement management: RxAdvance facilitates the acquisition of specialty drugs from the preferred specialty pharmacy network. These preferred specialty pharmacies are offered best-in-market pricing by leveraging the RxGalaxy (a wholly owned subsidiary of RxAdvance) wholesaler relationship
  4. Case management: The system leverages Patient-Rx360°™ delivered through IntelligentDUR360°Gateway™ to create a concise and coherent case action plan for all stakeholders involved in the well-being of the patient. Coupled with dynamic alerts, the operational 360° dashboard view empowers case managers to prioritize their outreach actions and enables members to receive optimal care from prescribers and pharmacists
  5. Concurrent case management: RxAdvance automates the process of enrolling targeted members in medication therapy management programs. Information is delivered during the care process by Patient-Rx360°™ to ensure all care professionals are making informed treatment decisions

Adverse Drug Event Management Services

Preventable medication errors are estimated to impact more than 7 million patients, contribute to 7,000 deaths annually, and cost in excess of $21 billion per year. This fundamental problem is inherent within the current practice of prescribing and dispensing medications without a comprehensive 360° view of patients’ age and gender, disease conditions, medications, and pharmacogenomics data. Conventional PBMs’ inability to aggregate, analyze, and deliver such actionable intelligence to avoid Adverse Drug Events (ADEs) at the point of care, point of sale, and to the patients is largely due to the widespread reliance on outdated, incomplete, and fragmented legacy PBM platforms.

RxAdvance’s three-phase approach to eliminating ADEs

  1. Physician-led CMR: As a first line of defense, RxAdvance will comprehensively assess a new patient’s accumulated drug regimen over a period of time. This review is designed to determine any inappropriate medications and recommend regimen changes to improve disease-conditions and balance this with the patient’s overall quality of life. To optimize the effectiveness of this comprehensive review process, RxAdvance as part of initial implementation, aggregates all patient-specific information (360° view) derived from their historical pharmacy and medical data to correct accumulated retrospective drug inefficacies. All issues and recommendations are immediately sent as alerts to all care stakeholders (prescribers, pharmacists, patients, and clinical/pharmacy staff of payers) through IntelligentDUR360°Gateway™. Patients are prioritized depending upon the level of risk pertaining to their drug inefficacies with corresponding alerts sent to physicians to take appropriate action at the point of care. To support an effective physician/patient consultation, IntelligentDUR360°Gateway™ provides prescribers with a comprehensive view of ADEs and related information, prompting a physician to conduct a comprehensive medication review (CMR). Easy entry of OTC and non-PBM recorded medications is also supported during this process. Using all sources of drugs registered during the patient visit, the system generates a new CMR that identifies and eliminates medications for which adverse drug events outweigh the benefits for the patient’s overall quality of life.
  2. Pharmacogenomics analysis for drug efficacy: After identifying the right prescription regimen, the system automatically generates alerts to the provider to control costs, improve quality, and remove ADEs. Depending on the diagnosis/prescription, the system also prompts the physician to conduct a recommended selective pharmacogenomics analysis. During the follow-up visit, based on results from pharmacogenomics analysis, the drugs that are ineffective are immediately removed or replaced. For example, a recent study has shown that the two most common drugs prescribed to treat Alzheimer’s are effective only 30 percent of the time due to the patient’s genetics. The total annual drug spend for these two medications exceeds $1.5B, resulting in an annual waste exceeding $1.1B due to lack of pharmacogenomics analysis.
  3. Prospective ADE elimination: At the point of care, when the prescriber is prescribing a new drug, the system will validate against the corrected baseline regimen to ensure the new drug added to the patient’s prescription registry is actually improving the patient’s overall quality of life. If a newly prescribed drug exceeds the cost threshold or has individual variability in drug therapy response due to the patient’s genetic makeup, the provider will be directed to go through a prior authorization process to conduct a selective pharmacogenomics analysis to control ineffaceable drug usage.