“We’ll help you buy fewer drugs”
No area of medical costs is increasing as quickly as prescription drugs. New drugs,new delivery systems, pain management programs, increased use of opioids and complicated polypharmacy all cause medical cases to spin out of control. Most groups buy their pharmaceuticals through a Pharmacy Benefit Manager (PBM) yet costs continue to soar and patients’ ability to find affordable prescriptions becomes harder and harder. Why isn’t this working?
PBMs make money ONLY WHEN THEY SELL DRUGS. Seems simple enough; each PBM wants to sell you drugs by convincing you they will sell them for less than the other guy. But, in the end, the more you buy, the more money they make. It seems unlikely they would want to help reduce useage.
OMCA, and its PharmCLEAR® program, wants to help your group use FEWER drugs and spend LESS money. A major part of your program must be an effective, transparent PBM to secure the best pricing on the drugs you will have to buy. But the missing link in many programs is effective pharmaceutical utilization review (PUR). The key to this is an aggressive, thorough approach beginning with the design of your formulary and selection of your PBM and continuing through the effective review of prescriptions that are potentially abused, unnecessary, duplicative and dangerous.
OMCA’s clinical staff is second to none. We use registered nurses, registered pharmacists (PharmD’s), MDs (anesthesiologists and other specialists) and PhDs (pharmaceutical economist, psychologist). Our staff is strong in peer-to-peer conversations with both pharmacists and prescribing physicians. Frequently prescription patterns and use of multiple opioids can be best controlled by this peer-to-peer intervention. The most successful interventions are those that involve peer matches. For instance, a pharmacist frequently cannot reach or persuade a neurosurgeon to change a pain management regimen. An MD, PhD is generally more successful.
OMCA can help you
- Pick the right PBM
- Competitive pricing
- Complete transparency
- A formulary that maximizes your financial interest
- No hidden rebates or spread pricing
- Adequate network
- Audit monthly PBM report to
- Identify unusual patterns
- Identify and tag commencement of opioids
- Identify cases that should have resolved
- Identify commencement of high-cost drugs
Issues identified through monthly audits are referred to PUR. There an appropriate clinical professional collects the facts of the case in an attempt to determine the medical necessity of the medication being prescribed. Is it appropriate for the diagnosis, should its use have terminated by now, is it being prescribed from more than one source, should the prescribing physician be drug-testing the patient, if needed, is there an opioids contract in place with the patient, etc?
After identifying the appropriate issues, OMCA clinical staff will contact the prescribing physician to determine if there should be a change in prescribing patterns. This may be done by mail or phone and may be conducted by an RN, PharmD, MD and/or PhD as required. Infrequently state regulators become involved if the prescribing physician’s actions should so warrant.
OMCA sells PharmCLEAR® services to carriers, third-party administrators, and self-funded employers. These programs are also effective for excess/reinsurance
To hear more about OMCA Pharmaceutical solutions, contact Rosalie Faris, RN,
BSN, CCM, COHN-S at firstname.lastname@example.org. We’ll help you buy fewer drugs.
From our Clients & Colleagues
Madonna Senger Workers' Comp Adjuster
“The best network ever was the original PPO network of OMCA.”