PPCN offers pharmacy claims analysis by licensed clinical pharmacists. This includes a systematic review to identify cost savings opportunities, medication-related problems, adherence interventions, and gaps in care while designing an action plan to resolve these issues. Pharmacy claim reviews are customer specific and can be episodic, periodic, or ongoing.
Why a Pharmacy Claims Review?
Medication-related problems and medication mismanagement are public health issues in the United States. The Office of Disease Prevention and Health Promotion (https://health.gov/our-work/health-care-quality/adverse-drug-events) reports that each year, in the outpatient setting, adverse drug events account for:
- Over 3.5 million physician office visits
- An estimated 1 million emergency department visits
- Approximately 125,000 hospital admissions
PPCN is 100% independent and fully committed to improving patient outcomes, which in turn generates savings for the plan sponsor and its members. There are no rebate arrangements or soft-dollar reimbursements that can influence these reviews.
Prescribers and patients are much more likely to accept and implement recommendations from independent reviews that are not associated with the Pharmacy Benefit Manager. Consequently, PPCN’s reviews yield superior results to traditional programs. PPCN is 100% transparent when providing analysis and outcomes.
Review Components:
- Claims analysis to identify high risk and high-cost interventions prioritized by drug spend, number of medications, and chronic conditions
- Targeted reviews include identification of potential drug interactions, therapeutic duplication, multiple prescribers, possible adverse drug reactions, polypharmacy issues, and generic and therapeutic substitution opportunities.
- Action plan and recommendations
- Communication with the prescribing provider and plan member
- Reconciliation of recommendations and communication based upon monthly analysis
- Reporting to quantify projected cost savings and the actual cost savings
Benefits:
- Rapid results are seen by plan members and employers, with immediate cost savings.
- Reduction of drug costs by eliminating duplicate, ineffective, and/or expensive therapy
- Reduction of physician visits, emergency room visits, hospitalizations, tests, and procedures due to less than effective or inappropriate therapy
- The new drug regimen should yield improved clinical outcomes.
- The program generates 2:1 Return on Investment.
