Value Added Services

Pharmacy benefit managers (PBMs) have a unique opportunity to promote health and generate value in the healthcare system. Today, PBMs are largely evaluated on their ability to control costs rather than improve health. RxAdvance’s unique value proposition comprise of value creation through care stakeholder’s engagement, system-driven compliance management and standing shoulder-to-shoulder with plan sponsors to take pharmacy risk. This is accomplished through, integration of pharmacy, medical, clinical and lab data, stronger partnerships with patients, physicians, pharmacists and clinical/pharmacy staff of health plans, and improved measurement and reporting of results. Incentives for PBMs to promote value should drive innovation and improve health outcomes.

Our Value Added Services include:

Care Stakeholder Services

Effective and efficient care stakeholder engagement for better health outcomes

Prescribers, pharmacists, patients, and clinical/pharmacy staff of payers are frustrated by having to access too many portals and hard copy reports in order to obtain a comprehensive view of a patient’s health, current/past care activities, actionable drug utilization review (DUR) information, comprehensive pharmacy/medical patient profiles, and real-time alerts. The RxAdvance solution to this problem is to deliver actionable information into care stakeholders’ respective workflows at every stage of the care continuum. Putting the right information into the hands of both service providers and members maximizes effective cost management and service excellence.

Comprehensive patient-specific (Patient-Rx360°™) information directly into the workflows of these care stakeholders:

  • To physicians — EMR/PM/e-prescription workflow
  • To pharmacists — pharmacy claims submission workflow
  • To patients — mobile devices
  • To clinical/pharmacy staff of plan sponsors — care/case/disease/UM workflows

Actionable information into care delivery workflows as a single message after instantly extracting, analyzing, and packaging critical information:

  • When an eligibility/authorization/formulary request originates at Point of Care (PoC)
  • When pharmacy claim transaction originates at Point of Sale (PoS)
  • When member-specific quality/cost information is generated in Collaborative PBM Cloud™
  • When clinical/pharmacy staff of a plan sponsor need to be involved in real-time collaborative decision making for better health outcomes

Compliance Management Services

RxAdvance’s guiding principles include interpreting the CMS/state/plan sponsor-specific compliance guidelines, building consensus between plan sponsors and RxAdvance, and configuring the Collaborative PBM Cloud™ to achieve the highest possible degree of compliance automation with minimal personnel involvement.

Overarching line of business guidelines: RxAdvance’s Collaborative PBM Cloud™ comes with built-in library of federal and state compliance guidelines that were interpreted and configured into the system so that compliance is accomplished both at transactional and operational levels.

Plan sponsor benefit design guidelines: As part of onboarding a plan sponsor, RxAdvance SME’s evaluate, interpret, and configure plan sponsor benefit design guidelines. Leveraging Collaborative PBM Cloud™, RxAdvance brings transparency to plan sponsors by seamlessly sharing the interpreted configuration. Upon approval by the plan sponsor, RxAdvance promotes the configuration to production.

Ongoing regulatory compliance changes: RxAdvance SMEs provide up-to-date responses to federal guidance and new and pending legislation. RxAdvance is part of a compliance coalition team that participates in weekly user calls and industry conferences and monitors the direction of federal programs.

PBM Service Level Agreement (SLA) Compliance: Collaborative PBM Cloud™ enables RxAdvance to configure all elements of plan, sponsor-specific ALAs, providing service delivery staff with tools and workflow triggers to meet SLA requirements. Through AdvanceESM, RxAdvance provides service managers and plan sponsor supervisors full and complete access to real-time service level activity.

Leveraging AI driven algorithms, Collaborative PBM Cloud™ continuously monitors preset service delivery thresholds which are configured during onboarding of a plan sponsor. This monitoring process proactively auto-triggers changes to service delivery resources including activation of third party overflow vendors to fulfill all agreed upon service levels. Proposed benefit design changes, (e.g. formulary/prior authorization modifications) can be modeled to promote effective service delivery management.

Audit Support: RxAdvance believes in giving full transparency to the plan sponsor regarding all PBM-related activity, eliminating the need for onsite plan sponsor audits. When it comes to regulatory agency audits, RxAdvance provides full access to the “auditor role” using role-based security. Through this role, the auditor is able to inspect the system-configuration rules, simulate a transaction, and validate the outcome. In addition, the system provides complete access to all member-level transactional information.

The table below illustrates a representative set of compliance requirements that are automated through Collaborative PBM Cloud™

Compliance RequirementRxAdvance Automation
MTMSystem monitors patient prescriptions, triggers alerts, pre-populates CMR, generates PML and MAP, and queues up the P4P payment to support CMS mandated MTM requirements
Concurrent DURProcesses and analyzes all patient data (including drug, medical, dental, and lab) to send customized notifications to pharmacists and prescribers.
Coverage determinationsMonitors all determination requests against CMS guidelines from receipt to disposition and autogenerates all required documentation ensuring 100% compliance
Appeals and grievancesMonitor all five levels of appeals with automated timeline reporting and escalation protocols to ensure compliance with all guidelines
Formulary administration and changesBuilt-in CMS and HIX formulary requirements identify invalid RxCUIs, negative formulary changes, and tier formation and structural questions to eliminate compliance issues with benefit design changes
Rejected claims monitoringAutomated triggers to monitor all rejected claims for re-validation to eliminate audit issues and improve patient experience
Benefit coding and testingSimple setup, customization, and testing of more than 300 benefit designs
Part D reporting and data validationPre-validated Part D reporting structure and guidelines to automatically generate accurate and timely reports
Claims processing systemsAutomated override procedures for transition policies, emergency fills, LTC requirements, and custom messaging at POS to minimize invalid rejections
DEA validationComprehensive DEA database for real-time monitoring of incoming prescription types, DEA license types, and providers for accurate adjudication
Transition policyBuilt-in transition policy requirements to accurately track and identify existing and new patients, medications, and place of service
Part D reporting and data validationComprehensive data structure and analytics to identify patient location, disease state, medication, and enrollment history to auto-adjudicate potential Part B versus Part D reimbursement scenarios
TrOOP balanceAutomated capabilities to track and maintain TrOOP balances for new and existing patients

Global Pharmacy Risk Management

RxAdvance’s unique value proposition to plan sponsors includes the sharing of global pharmacy risk. In this partnership model, RxAdvance stands shoulder-to-shoulder with plan sponsors to share pharmacy and drug-imimpacted medical risk sharing.

RxAdvance’s global pharmacy risk management has two components:
1) Pharmacy risk sharing; and 2) Drug‐impacted medical risk sharing.

RxAdvance’s Global Pharmacy Risk Management 5-phase program includes:

  1. Analysis – RxAdvance seeks to identify all the relevant opportunities and risks for plan sponsors. RxAdvance aggregates all available data from medical claims, pharmacy claims, and clinical data to offer a comprehensive analysis of prior drug utilization. This analysis is accomplished by running historical data through Collaborative PBM Cloud™ platform, which applies artificial intelligence (AI) algorithms to list opportunities for plan sponsors. Possible opportunities include but are not limited to: 1) untapped generics usage; 2) medication therapy management (MTM) and coverage gap avoidance (CGP³); 3) medication adherence management (MAM); 4) effective specialty management; 5) increase in pharmacy related STAR ratings; 6) administrative fee savings; 7) unit drug cost savings; 8) increase in rebate income; 9) fraud, waste, and abuse-related opportunities and 10) avoidable drug-impacted medical costs.
  2. Engagement – RxAdvance engages the plan sponsor’s clinical/pharmacy staff to discuss opportunities and risks and collaboratively decide on program options. Based on the programs identified, RxAdvance engages with pharmacists at the point of sale while the plan sponsor engages with prescribers at the point of care and with members proactively.
  3. Implementation – RxAdvance collaboratively implements programs identified in the engagement process step. As part of the implementation stage, key performance metrics, success criteria, and program monitoring timelines are defined. All computations are clearly documented before the programs are initiated to ensure consistency of measurements.
  4. Monitoring – Each program is continually monitored for effectiveness and to identify any opportunity for appropriate recalibrations in order to achieve best possible results.
  5. Cost reduction – RxAdvance works withplan sponsors to compute cost reduction opportunities and the mitigation of clinical risks. Based on the clinical results accomplished and cost savings achieved, risk or reward is shared between the plan sponsor and RxAdvance in accordance with predefined contract terms.

Pharmacy Risk Sharing

The first step is to establish a projection of national pharmacy costs in theupcoming period using defined industry financial benchmarks. RxAdvance analyzes available information for trends and establishes a projected cost increase below this benchmark.

For example, if the national benchmark projects an increase of 5%–7% annually, then RxAdvance sets its RISK CAP at 4%. Current year pharmacy costs = $200M.Contract terms will thus be:

  • Contract year pharmacy costs should have been = $212M (6% increase as per the agreed national benchmark).
  • Plan sponsor reimburses RxAdvance = $208M (4% as per agreed RISK CAP).
  • Plan sponsor projected pharmacy cost savings = ($212M – $208M) = $4M

Scenario – A

  • For the contract year, the actual pharmacy costs = $200M.
  • RxAdvance saves = $208M – $200M = $8M.
  • RxAdvance reimburses 25% of the savings to plan sponsor = 25% * $8M = $2M

Scenario – B

  • For the contract year, the actual pharmacy costs = $214M
  • RxAdvance takes risk of $214M – $208M = $6M.
  • Plan sponsor reimburses 25% of the risk to RxAdvance = 25% * $6M = $1.5M

Drug-impacted Medical Risk Sharing

  • RxAdvance will work collaboratively with plan sponsors to establish the basis-for-computing drug-impacted medical costs out of total medical costs. This analysis leverages prior year(s) medical claims data to compute drug-impacted medical costs. Based upon these findings, RxAdvance and the plan sponsor mutually decide on the targeted cost reduction figure for the contract year. During the contract year, RxAdvance closely monitors actuals versus projections and works with the plan sponsor to ensure overall quality of care is optimized.
    • For example, current year total medical costs = $800M and current year drug-impacted medical costs = $200M.
  • Upside Scenario
    • Contract year actual drug-impacted medical costs = $150M
    • RxAdvance gets reimbursed from plan sponsor 25% of contract year savings = $200M-$150M =(25% * $50M) = $12.5M

In this way, RxAdvance offers a revolutionary global pharmacy risk sharing partnership that is unique in the PBM market place. To see what your actual savings could be, please contact RxAdvance for a demonstration at