For clients who want to further manage their formulary with minimal member impact, THP Rx offers an incentive formulary (also known as national preferred). The incentive formulary is designed to bring the greatest value to our clients and members while increasing the use of the lowest net-cost products. This formulary excludes 159 products from 4,000 medications on the market. These drugs offer no added clinical value over other medications that remain in the therapy class. Any members impacted by formulary exclusions will be asked to use a different medication that achieves the same health outcome at a lower cost. However, if a patient has a rare clinical need that requires a medication that is not in the formulary, THP Rx can provide a clear pathway to have an excluded drug covered.
THP Rx delivers a clinically-driven, customer focused, flexible plan design service. We offer the latest tools to maximize savings for plan sponsors, reduce gaps in care for patients and enable cost-effective clinical decision-making. With THP Rx and medical services in one location, our clinical pharmacy team can handle all medical coverage reviews for drug related requests as well as channel the dispensing of medications to the most cost-effective site of care.
Pharmacy data is often considered the best predictors of a patient’s health. Unlike medical claims data, which may appear weeks after the healthcare action and only a few times per year, pharmacy data come in real-time upon each prescription fill. At The Health Plan, we utilize pharmacy and medical data to generate actionable interventions to improve healthcare by making it more accessible, affordable and effective.
Integrated services provide:
- Healthier outcomes and enhanced coordination of care
- Simplified member experience
- Administrative efficiencies
- More complete data and consistent reporting
- Improved adherence monitoring
- Increased flexibility
- Better, smarter communication
Formulary & Plan Design Solutions
Advance Utilization Management
THP Rx’s standard formulary includes a broad range of drug choices and high rebate savings. We use advanced utilization management (AUM) programs to decrease client spend on their pharmacy benefit by driving members to the most clinically appropriate, cost-effective medications with flexibility to meet specific needs.
- Value AUM package holds certain restrictions across several therapy classes and encourages the use of generics over expensive brand alternatives, which are clinically appropriate. This helps keep costs down that encourages patient adherence.
- Advantage AUM gives members individual choice and access to clinically effective generic and brand name drugs.
- Electronic Prior Authorization (ePA) allow us to instantly return coverage decisions and seamlessly integrates within a physician’s electronic health record (EHR) or through our online web portal.
A proper pharmacy benefit design can help assure members achieve the best medication care, maintain and achieve best possible health states, and help reduce inappropriate utilization. THP Rx can create custom fit plan designs to help members find the right treatment along with avoiding unnecessary and excessive cost to the employer
THP Rx offers various plan designs that cover generic, brand name, and non-formulary options. Our formulary is developed with clinical supportive material to meet the members’ needs in a clinical and cost-effective manner. THP Rx also covers certain preventive medications and services to conform to the Patient Protection and Affordable Care Act (PPACA).
THP Rx offers a variety of channel solutions to help control pharmacy spending for both the client and member. THP partners with Express Scripts Pharmacy for mail order prescriptions and offers the following choices:
- Active Choice - Members choose to receive their prescriptions through participating retail pharmacies or move to home deliveries via Express Scripts for maintenance medications.
- Incentive Choice - Members can continue to fill a maintenance medication at a retail pharmacy after two fills for a higher copay or switch to mail order.
- Exclusive Home Delivery - Requires members to use Express Scripts mail order for medications after a limited number of fills at a retail pharmacy. The best solution for clients who want to maximize per-member-per-year savings.
- Exclusive Smart 90 - Allows members to receive two 30-day courtesy fill at a retail pharmacy before a penalty is triggered. Once the member has used their courtesy fills, the member must switch to 90-day supply at a network pharmacy or mail order.
THP RX in-house pharmacists promote patient safety by analyzing prescription claims data to identify issues which could be harmful or inappropriate for our members. Our pharmacists work with prescribers and patients to ensure the safety and health of our members. Our patient safety design program prevents adverse drug events caused by:
- Over- and under-utilization
- Drug-drug interactions
- Drug-disease interactions
- Long-term use of hypnotics
- Opioid dependency
- Narcotic oversight
- Therapeutic duplication
Opioid/Drug Dependency Programs
Since deaths from prescription painkillers have reached epidemic levels, THP Rx has initiated programs to help decrease this issue with our members.
- Opioid Management Programs - When a member receives their first opioid prescription, they are limited to a 5-day supply of the medication. During that time, members receive education from our Behavioural Health Department regarding the safety and risks of opioids. Members who are prescribed opioids for chronic pain conditions have their cases reviewed by a pharmacist to ensure that their prescription is appropriate and safe.
- Drug Dependency Program - For members who are already addicted to opioid medication, our in-house team utilizes pharmacotherapy and behavioural therapy to treat drug dependency. THP Rx covers buprenorphine-containing medications for the treatment of opioid dependency. Our Behavioral Health Team will contact the member to offer education and services to help the member with leading a narcotic-free life.
Our compound management solution allows plan sponsors to provide compound medications to patients while avoiding compounds that are high-cost or with limited-to-no established clinical efficacy. THP Rx reviews compound prescriptions through coverage review to determine if the ingredients being compounded for use are acceptable within standard coverage guidelines for safety and efficacy.
Our clinical staff continually reviews the specialty drug landscape and puts in place appropriate coverage rules and programs to achieve best practices. Management includes coverage for pharmacy benefit pathways and medical managed pharmaceuticals. THP looks for appropriate site of care (e.g. home infusion vs. hospital infusion) to minimize delivery cost of care delivery along with maximizing patient experience. Our narrow vendor network provides best practice with patient care and optimal cost management for the expanding and costly benefit.
THP requires prior authorization for all specialty medications. Some medications require step-therapy, which means that you need to try other medications first. THP limits all specialty medications to a 30-day supply per fill.
THP has the ability to implement custom programs, where appropriate, in order to meet a client need to steer to a lower cost site of care. THP redirects specific specialty medications from the medical benefit to the pharmacy benefit through utilization management where patients receive care from our specialist clinicians. Achieve an average savings of 8-12% through this solution.
Home infusion offers patients and plans the option to voluntarily redirect the administration of specialty drugs from high-cost sites of care like outpatient facilities to the home through outreach to patients and voluntary transition, where nursing support is available.