Our automated Coverage Determination program helps eliminate fraud, over-prescribing and risky drug interactions by tracking, flagging and reporting on prescription drugs that require additional inspection. This program is run exclusively by our Doctors and Pharmacists, providing for a more robust process when manual intervention is required.
Prior Authorizations and Appeals form the core of our Coverage Determination program. Each process, in collaboration with our client’s management teams, is custom tailored and modified throughout the lifecycle of the program in tandem with market dynamics.
a) Prior Authorization (PA)
Our talented physician-supervised pharmacists monitor our Prior Authorization (PA) program, reducing the standard procedure turnover time from 72 hours to 48 hours
All expedited requests are responded to within the first 24 hours, many within 6 hours
b) Appeals
For 2009, only 1.875% of Prior Authorizations reached first level appeal and of those, only 1.333% or 0.025% of PA’s reached Second Level IRE appeal
The precision of utilizing an experienced team of pharmacists and clinicians has benefits never before seen within typical plans
c) Exception Requests
Formulary Exception dispenses a non-formulary medication to a member, only if formulary medications have failed
Tier Exception allows the member to receive a Tier 4 medication at a Tier 3 coverage level or Tier 2 medication at Tier 1 coverage level, if the lower tier medication has proven ineffective for the patient
d) Step Therapy
Dispensing the safest and least expensive drug therapies (STEP1) to its plan participants, progressing to more expensive therapies (STEP2), only if the generic medications have failed to have a positive net impact
e) Quantity Limit
The set limit on the amount of a drug a member can receive
This is applied when the risk of significant side effects increases with doses higher than FDA-approved
