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 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
- Therapeutic duplication
Opioid/Drug Dependency Programs
Deaths from prescription opioid overdose have reached unprecedented levels. THP has implemented an Opioid Management Policy so that opioid usage can be optimally managed. This policy only allows a 5-day supply of an opioid when being filled by a patient who is opioid naïve. Exceptions are allowed for patients who have conditions such as chronic pain, cancer or end-of-life care. Additionally, long-acting opioids require review by a pharmacist to ensure that the opioid is being used appropriately for the patient’s condition.
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. THP has the ability to implement custom programs, where appropriate, in order to meet a client need and better control specialty medication costs. Management includes prior authorization, quantity limits, site of care consideration and best specialty drug pricing.
Prior Authorization- THP requires prior authorization for all specialty medications. This helps to ensure that the patient is taking the medication at the optimal dosage for the appropriate diagnosis in the most suitable and cost-effective care setting. Prior authorizations also take step management into consideration to see if the patient has tried less costly medications that could prove just as effective in treating their condition.
Site of Care- Appropriate site of care (e.g. home infusion vs. hospital infusion) can help to minimize cost along with maximizing patient experience. Site of care management offers the option to redirect the administration of specialty drugs from high-cost sites of care (e.g. outpatient facilities) to the home. Patients can still receive medications while in the comfort of their own home and still receiving nursing support. Accredo Convenient Care is a solution that helps to ensure access to home infusion services nation-wide.
Quantity Limits- THP limits all specialty medications to a 30-day supply per fill. This can help better manage costs and prevents stockpiling of costly specialty medications.
Specialty drug prices- THP works to allow member access to the best specialty drug pricing possible. Solutions such as SaveOn SP can also be used to help to lower specialty drug costs.