RxAdvance offers nirvanaRxCloud™, a national full-service pharmacy benefit management solution that leverages the Collaborative PBM Cloud™ platform to manage standard and specialty drug benefits with unmatched regulatory compliance and transparency. These comprehensive PBM services comprise of Administrative Services, Clinical Services, and Value-Add Services.
RxAdvance’s nirvanaRxCloud™ offers an unmatched suite of proven PBM administrative services. All services can be configured to meet each plan sponsor's specific needs with enhanced flexibility enabling customization of its service model. Only RxAdvance brings together the industry’s best and most sophisticated, collaborative, and unified enterprise platform to provide real healthcare value, cost control, and efficiency. RxAdvance provides its expertise to every plan sponsor to generate value-driven pharmacy benefit management, closing care gaps and improving outcomes. RxAdvance has a network of over 67,000 pharmacies that includes both retail and specialty pharmacy providers throughout the country. RxAdvance has highly competitive rebate contracts with all pharmaceutical companies.
RxAdvance offers following administrative services:
Compared to a plan sponsor’s medical benefit structure, a typical PBM’s pharmacy benefit structure is simplistic. In spite of this simplicity, current PBMs are unable to accommodate required benefit design flexibility. In order to manage a cost-effective benefit structure, RxAdvance believes this module should be very flexible and able to facilitate prospective cost and quality modeling for better financial/clinical outcomes.
Collaborative PBM Cloud™enables a completely integrated array of granular and flexible benefit design solutions.
This holistic approach to benefit design leverages a single integrated data model of Collaborative PBM Cloud™ that is highly configurable in real-time, employing a collaborative approach with plan sponsors to simplify and streamline the process of designing and implementing a variety of complex benefit design scenarios. This module also enables benefit design compliance.
RxAdvance believes that cost-effective and high-quality pharmacy product deployment requires that plan sponsor actuarial staff are able to easily access and analyze a pharmacy benefit structure and associated formulary. In other words, to compete effectively in the market, plan sponsors should be able to easily simulate cost modeling scenarios using proposed benefit changes and historical utilization data. Upon approval by plan sponsors, the implementation of the pharmacy benefit through RxAdvance is a seamless process that requires minimal manual intervention.
Ongoing maintenance, customization, and integration of the benefit design to align with patients’ needs, cost issues, medical benefit designs, and other dynamic market requirements are all streamlined through RxAdvance’s Collaborative PBM Cloud™ framework. Complete and dynamic modeling enables all plan stakeholders to see the im-pact of proposed changes, thereby creating a more robust decision-making process.
Additional features of this module include:
Model drug coverage strategies that leverage a library of more than 300 custom benefit designs for commercial and employer group plans
The ability to format a variety of deductible and out-of-pocket cost criteria to craft innovative benefit structures
Fully compliant benefit structures for Medicare, exchanges, and MMPs (Medicare-Medicaid Plans)
Custom benefit structures based on pharmacy networks, formulary, tiers, days’ supply, and drug types
Support for benefit programs such as RRA (Retail Refill Allowance), mandatory generic program, first fill limit, member pay difference, and copay incentive programs
Easy configuration of CMS copay requirements for various benefit stages and LIS
Design and implementation of various point of sale/point of care processes to achieve optimal clinical and financial outcomes
Formulary Management and Modeling Services
When it comes to formulary management, which encompasses a high complexity of interdependent variables, PBMs must leverage both Artificial Intelligence (AI) algorithm-driven benefit/formulary design and collaborative plan sponsor engagement. An AI-driven solution is required due to the magnitude of decision variables in the following areas:
New generic offerings — prospective
Drug utilization patterns
Rebate contract complexity
Multiple lines of business
P&T committee medication efficacy recommendations
Ingredient cost variations
RxAdvance’s AdvanceFormulary™ leverages this “first-in-market” AI capability that is built into Collaborative PBM Cloud™ with modules such as AdvanceClaims™, AdvanceSpecialty™, AdvanceAnalytics™, AdvancePNC™, and AdvanceRebate™. These services employ a unified data model to analyze both retrospective (e.g., historical claims data) and prospective (e.g., generics replacing brands) data to create a system-derived optimal formulary that results in superior clinical and financial outcomes for the plan sponsor.
AdvanceFormulary™ also provides a system-generated gap analysis enabling RxAdvance and plan sponsor staff
to work collaboratively to analyze the gap between the system-derived optimal formulary and an existing formulary to identify clinical and financial variances. Using these gaps as a foundation, both RxAdvance and the plan sponsor can conduct iterative dynamic modeling to develop a practical multi-year transition action plan. This transition action plan includes engaging providers at point of care and proactive member engagement through Intelligent DUR360° Gateway™ to enable the seamless adoption of formulary adjustments.
A dynamic computational modeling capability that considers all clinical and relevant financial variables
An ability to recommend selective pharmacogenomics analysis based on individual variability of drug therapy
A system-generated gap analysis highlighting differences between optimal and existing formularies
An ability to “accept/deny” at a line-item level system-recommend formulary changes
A system-generated multi-year transition action plan and corresponding formulary
Member and prescriber engagement tools for adoption based on habitual member and prescriber utilization patterns to derive an ideal formulary with optimal financial (lowest net cost) and clinical outcomes for plan sponsors
Recognizing that plan sponsors have unique formulary needs that require business user configuration to meet specific goals, RxAdvance provides clients with modeling and impactful analytics to derive the most efficient and cost-effective standard and specialty formularies. Formulary compliance is promoted through RxAdvance’s Collaborative PBM Cloud™ platform using extensive edits and alerts at point of care and point of sale by leveraging a seamless integration with clearinghouses as well as through proactive member engagement. RxAdvance will work with the Pharmacy and Therapeutics (P&T) committee to recommend new or revised utilization protocols throughout the year, providing formulary utilization visibility to plan sponsors.
In addition, AdvanceFormulary™ includes:
Management and design of a variety of formularies for Commercial, Medicare Part D, Medicaid, and Exchanges with a highly customizable and intuitive platform
Support for multiple third-party drug databases, classification systems, and drug attributes to build and manage a formulary
Configuration of drug lists, drug tiers, and utilization management rules (PA – Prior Authorization, ST – Step Therapy, and QL – Quantity Limits) for single or multiple formularies
Comprehensive and streamlined formulary change management process for efficient decision making and effective implementation, supported by the fully integrated Collaborative PBM Cloud™ platform
Powerful analytics to analyze drug utilization trends, Utilization Management (UM) edits, and plan-to-plan comparisons
Built-in CMS rules, guidelines, and RXCUI (RxNorm Concept Unique Identifer) crosswalk to seamlessly generate formulary and UM files
Customization and dynamic generation of compliant forms: PA, ST, member and provider notices, and drug lists
Pharmacy Network Contracting Services
Compared to a plan sponsor’s provider contracts, a PBM’s pharmacy network contracts are rudimentary and lack a variety of key characteristics: the granularity required to manage pharmacy payments effectively in real-time; the ability to incorporate performance-based quality/cost measurements; the ability to create an effective “mosaic” network that is completely aligned with plan sponsor membership needs; and incentive-based prospective and retrospective clinical services at Point of Sale.
AdvancePNC™ is a granular, multi-level configurable, and fully integrated module within AdvanceClaims™.
AdvancePNC™ delivers cost management, quality improvement, oversight, and incentive alignment features.
This module also facilitates prospective cost and quality modeling for better financial/clinical outcomes, enabling RxAdvance pharmacy network contracts to be on par with the plan sponsor’s provider contracts.
AdvancePNC™ services include:
National network of over 67,000 pharmacies including independents, chains, and specialty pharmacies
Leveraging additional messaging space on standard NCPDP D.O transactions to communicate actionable information to pharmacies, making the interaction with pharmacies software agnostic
The promotion of preferred contracting using quality and cost indices
Intelligence and guidance to maximize the impact of desktop/onsite audits
The ability to create “mosaic” networks (sub networks) to optimize better quality/cost outcomes
Real-time FWA alerts
System-driven streamlined contracting and credentialing process
Real-time modeling of actual paid amounts vs. plan sponsor contract guaranteed amounts
Claims Processing Services
In the marketplace, a conventional belief is that pharmacy claims processing is a commoditized and low value-add service. In spite of spending significant time and money on legacy claims engines, potential business value is not achieved by the current PBMs. These dated engines have fragmented and inflexible subsystems with multiple incompatible data models — and they need to be replaced. At RxAdvance, we believe claims processing is a core transactional service that has significant potential to be transformed into a high-value and low-cost service.
AdvanceClaims™delivers these needed transformations to plan sponsors:
Low-cost and high-value service is achieved through AdvanceClaims™, an integral component of Collaborative PBM Cloud™, which was built from the ground up using state-of-the-art technology that is highly flexible, scalable, and automated, and that provides adjudication of specialty and non-specialty claims. This adjudication engine offers unlimited flexibility to design benefits, formularies, pricing, pharmacy network contracts, and compliance changes through rule-based user configurable modules
Fully integrated system of record for eligibility, membership, prescribers, pharmacy network contracts, pricing, benefits, formularies, authorizations, and compliance rules enabling seamless claims adjudication
Rapid implementation is accomplished through user configurability that leads to dramatic improvement in timeliness, cost, and accuracy
Fully integrated and highly flexible Formulary Management Services (AdvanceFormulary™), a core component of AdvanceClaims™. Highly customizable to a payer’s membership and line of business. Facilitates proactive formulary modeling to optimize clinical and financial outcomes
At Point of Care, when an eligibility/benefit/authorization/formulary request is generated, Intelligent DUR360° Gateway™ instantaneously aggregates actionable information from multiple components of Collaborative PBM Cloud™ and delivers this information into the prescriber’s workflow as a single message
At Point of Sale, when pharmacy claims are submitted for adjudication, Intelligent DUR360° Gateway™ instantaneously aggregates actionable information from multiple components of Collaborative PBM Cloud™ and delivers this information into the pharmacist’s workflow as a single message
Proactive member engagement is initiated when patient-specific quality/cost information is generated in Collaborative PBM Cloud™ and is then delivered to the member’s smart mobile device using Intelligent DUR360° Gateway™
Clinical/pharmacy staff of plan sponsor are engaged collaboratively through Patient-Rx360°™ to reduce pharmacy costs and avoidable drug-impacted medical costs, and improve health outcomes
Plan sponsors continue to be frustrated with PBMs’ inability to provide timely data, analytics, reporting, and visibility for effectively managing pharmacy and medical risk. It is vital to fully integrate PBM-generated and plan sponsor-generated data to understand and influence standard and specialty drug spend, medical spend, compliance, business needs, and financial forecasting, and to effectively manage administrative and medical risk. Currently, no PBM delivers comprehensive and patient-specific actionable information in real-time to prescribers, pharmacists, members, and clinical/pharmacy staff of the payer to create better health outcomes. Dynamic modeling capabilities are also absent in the current PBM service offerings.
Rebate Management and Modeling Services
By design, rebate management services provided by large PBMs are not seamlessly transparent to a level that enables plan sponsors to make effective decisions. Typical financial processes used in business decisions such as formulary and benefit design, new product launching, budgeting and forecasting, and predictive modeling are not provided by these PBMs’ rebate tools. This causes plan sponsors to miss out on a significant savings opportunities.
AdvanceRebate™ changes this paradigm by providing a seamless, information-rich, and predictable cost savings solution. Using artificial intelligence algorithms, AdvanceRebate™, leveraging Collaborative PBM Cloud™, derives an optimal formulary/benefit design that takes into consideration all the products/plans and their respective utilization, P&T committee therapeutic recommendations, plan-paid amount, and member-paid amount. RxAdvance has over 150 competitively negotiated rebate contracts with all pharmaceutical companies across all lines of business.
Designed with health plan staff in mind, AdvanceRebate™ includes the following sub-modules:
Rebate contract management
Rebate modeling, data analytics, and forecasting
Automatic rebate invoicing generation
Dynamic rebate reporting
AdvanceRebate™ services include:
Competitive rebate contracts for all manufacturers inclusive of supplemental rebate contracts
An integrated, comprehensive, and flexible rebate management platform that enables contract setup and maintenance with minimal personnel support
A dynamic contract-modeling tool to aid renegotiation with manufacturers, allowing the simulation of ‘what if’ scenarios to prepare and respond to contractual opportunities
Instantaneous/easy-to-model formulary changes, which effectively support the P&T committee process with potential rebate impacts of proposed changes
Full and transparent access to all rebate results, for all stakeholders
Real-time performance of rebate contracts based on preset thresholds to determine planned to actual results
The current business model of PBMs involves providing only administrative/limited clinical services, forcing plan sponsors to outsource various critical functions to multiple vendors. As a result, vital information for critical decision-making is dispersed across disconnected and inflexible vendor subsystems, making it impossible to obtain a comprehensive 360° view for the care stakeholder at the Point of Service.
RxAdvance’s unique value proposition to the plan sponsor is to provide comprehensive drug benefit management services without outsourcing a single critical function. These comprehensive services are offered through the Collaborative PBM Cloud™ platform, which is built on a unified data model. As an overlay on Collaborative PBM Cloud™, AdvanceESM™ (Enterprise Service Manager) extracts and consolidates information across all departments of the PBM, providing plan sponsors with a 360° view that enhances critical health/financial decision-making and results in best outcomes.
When a prescriber requests services from a CSR, comprehensive information comprising eligibility, benefits, accumulators, prior authorization, formulary verifications, drug utilization reviews, coverage gap and prescription planning, adherence, proactive FWA index, and MTM are provided via Patient-Rx360°™.When a prescriber requests services from a CSR, comprehensive information comprising eligibility, benefits, accumulators, prior authorization, formulary verifications, drug utilization reviews, coverage gap and prescription planning, adherence, proactive FWA index, and MTM are provided via Patient-Rx360°™.In addition, AdvanceESM™ promotes effective prescribing and utilization patterns through P4P programs
When a pharmacist requests services from a CSR, comprehensive information comprising eligibility, benefits, accumulators, prior authorization, formulary verifications, drug utilization reviews, coverage gap and prescription planning, adherence, proactive FWA index, MTM, claims, and financial reconciliation are provided via Patient-Rx360°™. In addition, AdvanceESM™ promotes effective dispensing and utilization patterns through P4P programs
When a patient requests services from a CSR, comprehensive information comprising eligibility, benefits, accumulators, prior authorization, formulary verifications, drug utilization reviews, coveragegap and prescription planning, cost saving opportunities, adherence, and MTM are provided viaPatient-Rx360°™. In addition, AdvanceESM™ enables the CSR to educate the member to optimizetheir prescriber and pharmacist consultations
AdvanceESM™empowers plan sponsor staff:
By pushing comprehensive patient information — eligibility, benefits, accumulators, prior authorization, formulary verifications, drug utilization reviews, coverage gap and prescription planning, cost saving opportunities, adherence, and MTM information through Intelligent DUR360° Gateway™ into customer service, case and care management, and utilization management workflows, AdvanceESM™ facilitates effective member engagement and optimal health/cost outcomes.
By providing unprecedented operational visibility to conduct PBM oversight functions, such as monitoring contractual obligations and service level agreements (SLAs), with full insight into compliance and regulatory requirements/performance
With an integrated and comprehensive view of the utilization of drug benefits by prescribers, pharmacists,
and members, enabling alignment of respective incentives: >>> Prescriber – optimize contracts through targeted P4P programs >>> Pharmacist – modify pharmacy network contracts for best quality/cost outcomes >>> Member – adjust the benefit design and out-of-pocket costs
These incentive recalibrations will enable the plan sponsor to effectively manage overall administrative/medical risk
Prior Authorization Services
Prior authorizations (PA) too often frustrate and impede quality care, while adding 20 hours per week to the administrative burden of medical practices, and costing the healthcare system a staggering $69 billion annually. Current stand-alone PA software systems, isolated and unable to integrate medical, pharmacy and lab data, lack a comprehensive view of the patient. They also fragment workflows and make it hard to keep up with changing state and federal regulations.
By leveraging pharmacy, medical, and lab claims data, AdvancePA™ delivers automated PA decision making and clinical pathways to prescribers. It is an integral part of the claims processing system, is rule-based and is easily configurable. Options for configuration extend beyond patients’ clinical and medical needs to include optional prescriber metrics such as prescriber utilization, quality and cost indices, and prescribing patterns. This enables further automation and additional reductions in abuse and misuse.
The comprehensive workflow capabilities of AdvancePA™ connect and support everyone engaged in a patient’s care — prescriber, nurse practitioners, medical directors, pharmacy technicians, and pharmacy directors. Communication with prescribers, pharmacists and patients integrates versatilely and seamlessly with electronic prior authorization (ePA), voice, email, fax, web, and mobile cloud interfaces. AdvancePA™, AdvanceClaims™ and AdvanceFormulary™ share data, rulesets and workflows, decreasing errors and increasing process efficiencies.
Drug driven rule sets and inbuilt machine learning enable AdvancePA™ disease specific algorithms to limit pharmacy staff requirements. They also ensure ultimate consistency among reviewers as well as system driven compliance, resulting in lower, plan sponsor administrative fees. In addition, AdvancePA™ reduces unnecessary administrative burdens for medical practices. In turn, AdvancePA™ reduces unnecessary physician offices’ administrative burden, streamlining PAs, resulting in provider contracting leverage for plan sponsors.
Forty-five percent of the US population suffers from one or more chronic conditions, requiring long-term maintenance medication. It is a well-established fact in the industry that approximately half of these chronic patients are nonadherent to their complex medication regimens. AdvanceMobile™ integrates all demographic, medical, pharmacy, and lab data to derive a 360° view of the member opportunities surrounding cost and quality. The personalized health coach provided by AdvanceMobile™ drives constant engagement through gamification, allowing the app to more meaningfully influence consumer behavior. This disease-driven mobile platform encourages members to make intelligent health and well-being decisions, leading to unparalleled member cost reduction and quality improvement. In addition, the 360° member view provided by AdvanceMobile™ will allow plan sponsors to replace all existing member apps, for a single comprehensive and configurable platform across all membership.
Personalized Health Dashboard All available health information is integrated to provide a personalized dashboard of current health conditions and associated medications. Users can also toggle to see a personal list of all actionable alerts, highlighting opportunities for out-of-pocket cost reduction, quality improvement, adverse drug event reduction, and adherence improvement. Attention to and completion of these alerts is encouraged through rewards and gamification.
My Medical Conditions and Medication The homepage lists all member- specific medical conditions. Clicking on a condition will display all associated prescriptions with a corresponding personal adherence score.
My Reminders Member-specific reminders include physician visits, medication reminders, and vital recordings reminders.
Disease-Driven Drug Information Drug-specific cost savings, quality improvement, and adherence improvement alerts include:
Cost Savings Alerts
Medication Adherence Alerts
My Rewards Gamification empowers engagement. Members earn points by completing achievable health goals and bonus missions defined through their specific medical conditions, medications, weight, age, and gender. They are consistently engaged for the opportunity to redeem points in exchange for plan sponsor-defined rewards. Through engagement, this rewards program encourages the development of long-term healthy habits. Additional features include multi-layer rewards schedules, leaderboards, and achievement based badges. Motivate members to collect them all!
Insurance Information Member access tools include:
Drug and procedure cost estimator
Tiers and copay information
Explanation of benefits
Donut hole prediction and prescription planning
RxAdvance’s staff of experienced pharmacists and care managers provide plan sponsors with clinically-driven services focused on safety, efficacy, and cost containment. UsingCollaborative PBM Cloud™, RxAdvance plan sponsors will receive value-added clinical analyses, reporting, and recommendations that will improve clinical outcomes while controlling costs.
Due to PBMs’ inability to conduct impactful MTM services, plan sponsors are forced to outsource MTM services 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 Intelligent DUR360° 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 CareFully 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
>> 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
Pharmacy-Integrated Total Care Services
Forty-five to fifty percent of the overall US population has at least one chronic condition, and one in four Americans have multiple chronic conditions. This population utilizes approximately 86% of the total US healthcare spend. While pharmacotherapeutic research has produced many novel therapies to reduce the disease burden of chronic conditions, many patients are still unable to control their illness due to prescription and care plan non-adherence.
At RxAdvance, we believe that engaging and motivating this population to take charge of their health early in their diagnosis will reduce avoidable medical costs significantly. Technology lies at the heart of RxAdvance’s solution. Smart-phones, machine learning, and connected devices are reshaping the way people interact with the world, and these same technologies should reshape healthcare. From a patient perspective, these technologies need to be convenient and interactive in order to reduce costs while improving care experience. RxAdvance’s Collaborative PBM Cloud™ delivers targeted actionable intelligence at all nodes of the care continuum, while continuing to support, educate, and engage patients as a companion in their health journey.
“PBMs have a unique opportunity to improve the quality of care, reduce the cost of care, and impact adherence due to their integral part in the transaction cycle from the Point-of-Care to the Point-of-Sale.”
RxAdvance harnesses this opportunity through the following approach:
1. Care-Level Identification: When a member receives an initial diagnosis of a chronic condition, RxAdvance’s platform analyzes the members’ medical, pharmacy, and lab information to assign the member to an appropriate care level. RxAdvance offers a three-tiered solution to address the specific needs of chronic care members. Each tiered solution increases in complexity based upon the level of care required by individual members in the corresponding risk band.
2. Enrollment and Onboarding: Once the member is classified into an appropriate care level, prescribers and pharmacists are alerted to review the member’s prescription plan. At the Point-of-Care during a refill/new prescription, the Intelligent DUR360° Gateway™ system alerts prescribers with adherence-related information that prompts a prescriber 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 optimal prescription regimen, the patient is recommended to a health plan-sponsored total care plan.
3. Mobile-Enabled Member Engagement: Through AdvanceMobile™, members are engaged in an interactive app-driven rewards program. AdvanceMobile’s gamification model provides incentives for completing different health goals, which vary at different steps of the member’s treatment journey. After enrollment, the app will deliver targeted adherence goals and other care plan tasks personalized to the member’s health needs. For eligible members in care level 2, AdvanceTotalCare™ aggregates, organizes, and delivers medications through a disposable pre-filled pill tray.
Ongoing Communication and Dynamic Care Plans: AdvanceTotalCare™ communicates efficiently with all care stakeholders to promote positive adherence to medication and care plans. As the Collaborative PBM Cloud™ receives updated claims and medical data specific to each member, care plans are updated to respond efficiently to new information. Any member-specific quality of care measures identified by the plan sponsor are also communicated to the members. Members are encouraged to report medication adherence and vital recordings through the AdvanceMobile™ app, and are given rewards for positive engagement and healthy behaviors.
1. nirvanaAccountableCare™ Service
For the highest risk chronic condition members (approximately 2 – 5 % of total population), RxAdvance offers nirvanaAccountableCare™ – a complete custom, risk-sharing solution. Equipped with an intelligent home-care, medication adherence, and vital sign monitoring system (nirvanaSmart™), as well a physician/nurse house call program, nirvanaAccountableCare™ was created to manage the most unmanaged portion of managed care. RxAdvance’s personal care advisors help members make sense of their diagnosis and teach them about medication and wellness habits that can improve their health status.
Coverage Gap Prediction & Prescription Planning (CGP³) 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 in order 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. This prescription planning solution can also be used for all lines of business to reduce overall pharmacy cost.
Intelligent DUR360° Gateway™ automatically generates a list of patients who will approach the coverage gap by using the previous year’s pharmacy claims data and patient-specific disease conditions
Post identification, the system generates a therapeutic alternative path that extends the coverage gap and proactively encourages members to engage with the prescriber
During the subsequent patient visit with the prescriber, Intelligent DUR360° Gateway™ alerts the prescriber about coverage gap alternatives available to the patient and enables the prescriber to select an alternative prescription regimen to mitigate the impact of the coverage gap and increase adherence
Intelligent DUR360° Gateway™ proactively informs clinical and pharmacy staff of RxAdvance and plan sponsors about patients and prescribers who are ignoring coverage gap system alerts and generates outreach communication alerts
Intelligent DUR360° Gateway™ also notifies the clinical/pharmacy staff of the 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
RxAdvance believes it necessary for a specialty management model to focus on value and outcomes, incorporation of limited disruption to physician work flow, and no additional effort for the plan sponsor to reconcile medical and pharmacy claims.
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 2018. 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 “value-based & outcome-driven” specialty management model. The RxAdvance solution to this growing problem is its full-service process for specialty management, supported by the RxAdvance Collaborative PBM Cloud™
The streamlined 10-step process is grouped into three stages: Onboarding, Diagnosis & Administration, and Continuing Care & Monitoring. Onboarding consists of RxAdvance integrating all the health plan’s data into the Collaborative PBM Cloud™ to derive the optimal client-specific specialty management solution. Then, with Diagnosis & Administration, RxAdvance comprehensively manages prior authorizations and facilitates in the acquisition of specialty drugs. In the last stage, care managers, caretakers, and patients work collaboratively using advanced care protocols to optimize overall health outcomes by improving adherence and preventing adverse drug events.
Continuing Care & Monitoring >> Case and Concurrent Management >> Financial Reconciliation >> Monitoring and Measuring >> Outcome Reporting Management
While all specialty management features are offered with nirvanaRxCloud™ full service PBM, RxAdvance also offers nirvanaSpecialty™ as a carve-out service designed to supplement a plan sponsor’s current PBM.
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 patients is largely due to the widespread reliance on outdated, incomplete, and fragmented legacy PBM platforms.
AdvanceADEM™ eliminates ADEs by leveraging a three-phase approach:
Physician-led CMR: As a first line of defense, RxAdvance will comprehensively assess a new patient’s accumulated drug regimen. This review is designed to determine any inappropriate medications and recommend regimen changes to improve disease-conditions and 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 Intelligent DUR360° Gateway™. Patients are prioritized depending upon the level of risk pertaining to their drug inefficacies with corresponding alerts sent to prescribers to take appropriate action at the point of care. To support an effective prescriber/patient consultation, Intelligent DUR360° Gateway™ provides prescribers with a comprehensive view of ADEs and related information, prompting a prescriber 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.
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 prescriber to conduct a recommended selective pharma-cogenomics 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.
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 inefficacious drug usage.
Value Added Services
Pharmacy benefit managers 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 comprises 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.
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°Gateway™) information directly into the workflows of these car stakeholders: >> To prescribers – EMR/PM/e-prescription workflow >> To pharmacists – pharmacy claims submission workflow >> To member – 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.
Line of Business Guidelines: RxAdvance’s Collaborative PBM Cloud™ comes with a built-in library of federal and state compliance guidelines that were interpreted and config-ured into the system so that compliance is accomplished at both transactional and operational levels.
Plan Sponsor Benefit Design Guidelines: As part of onboarding a plan sponsor, RxAdvance SMEs 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 Level Agreement (SLA) Compliance: Collaborative PBM Cloud™ enables RxAdvance to configure all elements of plan sponsor-specific SLAs, providing service delivery staff with tools and workflow triggers to meet SLA requirements. Through AdvanceESM™, RxAdvance provides service managers and plan sponsor supervisors full access to real-time service-level activity. Leveraging AI-driven algorithms, Collaborative PBM Cloud™ continuously monitors preset service delivery thresholds, which are configured during the onboarding process. This monitoring proactively 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: Collaborative PBM Cloud™ enables RxAdvance to configure all elements of plan sponsor-specific SLAs, providing service delivery staff with tools and workflow triggers to meet SLA requirements. Through AdvanceESM™, RxAdvance provides service managers and plan sponsor supervisors full access to real-time service-level activity. Leveraging AI-driven algorithms, Collaborative PBM Cloud™ continuously monitors preset service delivery thresholds, which are configured during the onboarding process. This monitoring proactively 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.
The table below illustrates a representative set of compliance requirements that are automated throughCollaborative PBM Cloud™
System monitors patient prescriptions, triggers alerts, pre-populates CMR, generates PML and MAP, and queues up the P4P payment to support CMS mandated MTM requirements
Processes and analyzes all patient data (including drug, medical, dental, and lab) to send customized notifications to pharmacists and prescribers.
Monitors all determination requests against CMS guidelines from receipt to disposition and autogenerates all required documentation ensuring 100% compliance
Appeals and grievances
Monitor all five levels of appeals with automated timeline reporting and escalation protocols to ensure compliance with all guidelines
Formulary administration and changes
Built-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 monitoring
Automated triggers to monitor all rejected claims for re-validation to eliminate audit issues and improve patient experience
Benefit coding and testing
Simple setup, customization, and testing of more than 300 benefit designs
Part D reporting and data validation
Pre-validated Part D reporting structure and guidelines to automatically generate accurate and timely reports
Claims processing systems
Automated override procedures for transition policies, emergency fills, LTC requirements, and custom messaging at POS to minimize invalid rejections
Comprehensive DEA database for real-time monitoring of incoming prescription types, DEA license types, and providers for accurate adjudication
Built-in transition policy requirements to accurately track and identify existing and new patients, medications, and place of service
Part D reporting and data validation
Comprehensive 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
Automated 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 addition to comprehensive PBM services. This partnership model, in which RxAdvance stands shoulder-to-shoulder with plan sponsors to share risk, has never been offered in the PBM marketplace. RxAdvance’s global pharmacy risk management has two components: RxAdvance’s global pharmacy risk management has two components:
1) Pharmacy risk sharing; and 2) Drug‐impacted medical risk sharing.
Global pharmacy risk management offered by RxAdvance involves the following five steps:
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
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 with plan 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 the upcoming 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 will set the risk cap lower than this national average. If the contract year actual pharmacy costs are less than the predefined risk cap amount, RxAdvance will reimburse a portion of the savings to the plan sponsor. If the contract year actual pharmacy costs are more than the predefined risk cap amount, RxAdvance will bear the majority of the risk. Upon analysis of historical data, these amounts (national benchmark and risk cap) will be presented as part of the proposal to the plan sponsor.
Avoidable Drug-Impacted Medical Risk Sharing
Due to poor pharmacy benefit management, avoidable drug-impacted medical costs are comparable to overall pharmacy costs in the industry. RxAdvance will work collaboratively with plan sponsors to establish the basis-for-computing avoidable drug-impacted medical costs out of total medical costs. This analysis leverages prior year(s) medical claims data to compute avoidable drug-impacted medical costs to establish the cost trend. 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, during the contract year, if RxAdvance is successful in lowering the actual avoidable drug-impacted medical costs, a percentage of savings will be reimbursed to RxAdvance.
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.
Contact us today to learn about forming a collaborative and risk-sharing partnership that cuts costs, improves quality of care, and offers unprecedented regulatory compliance and transparency.