Rebate or Direct Purchase: What a PBM Can Do for Your State’s ADAP Presented By: Sophia J. Byndloss, President
Our heart is in public health.™ Presentation Agenda Let’s Understand PBMs Overview of Traditional PBM Services What a PBM Can Do for You –Rebate State –Direct Purchase State Ramsell’s Experience With ADAPs Questions
Our heart is in public health.™ Understanding PBMs PBM Defined –A pharmacy benefits manager (PBM) is a third party administrator of prescription drug programs. –Responsible for the processing and payment of prescription drugs PBM Structure –Part of a larger pharmacy or separate entities
Our heart is in public health.™ Traditional PBM Services Formulary Management –Formulary Development –Formulary Maintenance Rebate Administration Pharmacy Network Clinical Services –P&T Committee –Prior Authorization Customer/Member Support Claims Adjudication Reporting
Our heart is in public health.™ Traditional PBM Services PBM Business Model –Traditional “spread pricing” –Administrative fees (i.e. per member or per claim, service) –Depend on revenues from pharmacy
Our heart is in public health.™ ADAP Saying… “Once you’ve seen one ADAP, you’ve seen one ADAP.”
Our heart is in public health.™ PBMs and Rebate States Pharmacy Network Management Claims Adjudication Formulary Management Clinical Services Reporting
Our heart is in public health.™ PBMs and Direct Purchase States Pharmacy Network Management Claims Adjudication Clinical Services Reporting
Our heart is in public health.™ Ramsell’s ADAP Experience Contractor for California ADAP since 1997 providing PBM+ services –Traditional PBM services –Enrollment and Eligibility management –Cost containment strategy development and implementation –Payer of last resort (coordination of benefits) claims management –CMS data exchange administration
Our heart is in public health.™ Ramsell’s ADAP Experience Contractor for California ADAP since 1997 providing PBM+ services –Clinical services –Collaboration in ADAP program administration –Reporting Contractor for California County ADAP providing PBM+ services
Our heart is in public health.™ Ramsell’s ADAP Experience Contractor for Washington ADAP since 2001 providing PBM services –Traditional PBM services
Our heart is in public health.™ Ramsell’s ADAP Experience Contractor for Flowers Heritage Foundation 2006 and 2008 for Montana Bridge the Gap (ADAP waitlist clients) –Pharmacy network management –Claims adjudication –Reporting
Our heart is in public health.™ Ramsell’s ADAP Experience Partner of ADAP community Developed tools for ADAP management –ADAP Management System
Our heart is in public health.™ Questions