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 2017. 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 must be replaced with an “Authorize & Manage” model. RxAdvance’s nirvanaSpecialty™ services accomplish this conversion from traditional “Buy & Bill” to “Authorize & Manage” model with no disruption to the physician work flow, with no additional effort for the plan sponsor to reconcile medical and pharmacy claims, and most importantly, the plan sponsor can continue to use their current PBM.
Authorize & Manage
Traditionally, physicians buy from their preferred vendors and pharmacies and bill the plan sponsor for the cost of the drug along with other costs, such as an administrative fee. In the case of RxAdvance’s “Authorize & Manage” model, when a patient visits a prescriber at the point of care to obtain a specialty medication, the physician submits and obtains a prior authorization (PA) from RxAdvance through SureScripts. Upon successful approval of the PA, the physician is able to submit the prescription through his/her preferred medium (fax, voice call, mail, EMR-ePA, Web Portal, etc.). When using nirvanaSpecialty™ services, we ensure that there will not be any changes to the physician’s workflow. RxAdvance’s specialty pharmacy then receives the prescriptions and uses the inbuilt logic to discern if the prescription should be adjudicated as a medical claim or pharmacy claim. After adjudicating the claim, RxAdvance delivers the drug to either the patient’s residence or to the physician’s workplace. In the latter case, the patient then re-visits the clinic to have the medication administered.
When it comes to the payments for the providers, RxAdvance submits separate invoices for medical claims and pharmacy claims, collects this balance from the plan sponsor, and pays the specialty pharmacy as per the agreed-upon rates. With regards to the prescriber, he/she then submits the medical claims with line items delineated (such as administrative fee, nurse’s time, etc.) to the plan sponsor. In these line items, there will be a line item for drug cost, which will be submitted complete with the drug’s corresponding j-code and a zero-value for drug cost.
Specialty Carve-Out Services
RxAdvance’s “Authorize & Manage” specialty management solution is an end-to-end process supported by the Collaborative PBM Cloud™ platform. nirvanaSpecialty™ management involves the following eight services:
- Specialty Formulary Management: RxAdvance leverages both “first-in-market” artificial intelligence (AI) capabilities and collaborative plan sponsor engagement to deliver a system-derived optimal specialty formulary that results in superior clinical and financial outcomes for the plan sponsor and members. AdvanceFormulary™ is a highly customizable and intuitive platform, embodying the capabilities to provide gap analysis to identify areas of clinical and financial improvement; to support multiple third-party drug databases and classification systems; to configure drug lists, tiers, and utilization management rules; to streamline formulary change management processes for efficient decision-making and implementation; to analyze drug utilization trends; and to harness built-in CMS rules and guidelines.
- Specialty 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 through AdvancePA™ and AdvanceFormulary™.
- Specialty Utilization Management: The system ensures that requested drugs meet P&T protocols (quantity limits, route of administration, and place of administration) by leveraging industry guidelines/ADE indications and therein delivers this information at Point of Care and Point of Sale through Intelligent DUR360° Gateway™.
- Specialty Procurement/ Distribution 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.
- Specialty (Pharmacy Portion of Medical Claim + Pharmacy) Claims Processing: Through AdvanceClaims™, RxAdvance delivers core claims processing transactional services as a high-value and low-cost service. Built from the ground up, this highly flexible, scalable, and automated system provides adjudication of specialty (pharmacy portion of medical claim + pharmacy) claims while offering unlimited flexibility to design benefits, formularies, pricing, pharmacy network contracts, and compliance changes through rule-based user configurable modules. RxAdvance’s fully integrated system of record allows for the derivation of actionable intelligence, which can be delivered at the point of care, point of sale, to members through our mobile application, and to the plan’s clinical and pharmacy staff.
- Specialty Case Management: The system leverages Patient-Rx360°™ delivered through Intelligent DUR360° 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.
- Specialty Concurrent Review 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.
- Specialty Pharmacy Network Management: Through AdvancePNC™, RxAdvance delivers cost management, quality improvement, oversight, and incentive alignment features. Further, RxAdvance facilitates prospective cost and quality modeling for improved financial and clinical outcomes, enabling RxAdvance Specialty Network contracts to be on par with the plan sponsor’s provider contracts.