Pharmaceutical Solutions
“Narcotic Abuse and Workers’ Compensation”
PharmCLEAR®
No area of workers’ compensation medical costs is increasing as fast as prescription drugs. New drugs, new delivery systems, pain management, increased use of opioids and complicated co-morbidity issues are causing post-award cases to exceed reserves and new cases to spiral out of control. Current pharmacy management techniques have not produced the clinical results needed to control these claims.
OMCA PharmCLEAR®
The OMCA PharmCLEAR® program offers several levels of services with increasing intensity to help control escalating and abusive pharmaceutical costs.
Basic Pharmaceutical Review
Our pharmacists (all PharmDs) review the file and issue a written report detailing usage and reasonableness, i.e. are those drugs being consumed by the claimant in keeping with best practices for the identified workers’ compensation diagnoses.
General pharmaceutical review
The review is based upon a summary developed by OMCA Nurse reviewers from the case file. The Nurse will then provide a written report detailing medication utilization and recommendations for more effective medical management of the file.
Physician review
The next step is for an M.D., PhD. Reviewer to write a comprehensive report with recommended course of action.
Physician intervention
Our Board Certified M.D., PhD. Reviewer personally contacts the treating physician to discuss a recommended change in the current medication management plan. The goal of this contact is the implementation of a more effective, less costly drug regimen.
Extended Review
Our clinical staff assumes management of the case for an agreed upon time. This usually will coincide with the claimant’s demonstrated acceptance of the new treatment plan and may involve case management intervention to deal with medical issues relevant to that change (e.g. detox and addiction issues).
Pharmacy Benefit Manager (PBM) Services
PBM programs are an important step in controlling workers’ compensation medical costs. However, PBM’s are not a panacea to pharmaceutical problems:
OMCA helps clients:
- Pick the right PBM vendor
- Competitive pricing
- Complete transparency
- Minimal “pass throughs”
- No hidden rebates/add ons
- Establish appropriate formulary
- Identify and Manage inappropriate/excessive cases through:
- Specialized workers’ compensation utilization review
- Address extent, duration and relatedness of prescriptions
- Intervene with treating physicians
Audit the PBM vendor
- Identify unusual patterns
- Early prediction/intervention of abusive situations
- Focus on off label/non scientific prescription usage
OMCA provides PharmCLEAR® and PBM value added services to carriers, third party administrators and self- funded employers. These programs have also been quite effective for excess/reinsurance carriers and prior to the offering of buyouts, MSAs or loss portfolio transfers.
To hear more about OMCA Pharmaceutical Solutions, contact Rosalie Faris, RN, BSN, CCM, COHN-S at rosalie.faris@omca.biz
From our Clients & Colleagues
Scott R. Medical Benefits Mgr, of a 2000+ employee group
"OMCA gives 6 star service on a 5 star scale."
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