1. Services Provider to Manage (J Code) Specialty Drugs Charged to the Medical Benefit Plan not to the PBM
HR Specialty Products & Services Catalogue Executive Summary
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Thomas A Ference
President & CEO
Human Resources Mining & Distribution Co
Locating, Validating and Accelerating HR  Innovation
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2. Medical Benefit ( J Code) Drug Management Services Provider
About 50% of the employer’s specialty drug spend is billed through the medical benefits plan not the PBM
Therein, the operational, clinical and financial conflicts of medical carriers and /or PBM’s can interfere with producing optimal and cost-effective patient outcomes.
Often, plan sponsors think the necessary management tools are in place to address “J ” billing code usage or other selection criteria when in fact, they are not.
Thus, this services provider has developed an integrated process that streamlines workflows with all necessary and involved parties to optimize clinical and financial outcomes for self-funded plan sponsors.

3. Medical Benefit ( J Code) Drug Management Services Provider
The process involves a pro-active and balanced coordination between a patient’s physician, an employer’s health plan administrator and a credentialed clinical team
The clinical team renders evidenced-based coverage recommendations with an opportunity for peer level clinical consultations.
The outcome for self-insured employers is greater visibility and transparency to actions that address increasingly complex high cost drug treatments in a cost-effective manner.

4. Medical Benefit ( J Code) Drug Management Services Provider
Expected ROI varies with a range of 1:1 to 8:1 depending on a variety of factors such as employer member demographics, disease mix and severity; and benefit design effect(s) on site of service and/or sourcing of drugs.
Medical Benefit ( J Code) Drug Management Services Provider

5. High Level Process Overview
Patient
Credentialed Clinical Assessment Team
Receive TPA -validated drug plan
Render coverage recommendation
Optional peer clinical consultation
Treatment
Plan
Notify Physician
Notify Health Plan TPA
Health Plan
Administrator

6. Example - Drug Costs Imbedded Within Medical
Sample Active Population
(Non-Medicare)
Medical Costs Incremental to PBM Costs
2% of members are expected to account for significant share of drug costs
~200 members per year
Unabated, 2018 is likely to be ~$4.0M without affirmation of clinical benefit
Continued growth of utilization and price increases can be expected to exceed PBM trends
Covered lives
10,000
Number of utilizers
200*
Expected
drug spend
(2% utilizers)
$3,267,840*
PMPM cost
$27.23*
*Service provider proprietary analytics modeling

7. Medical Benefit Drug Trend Management
With and Without J Code Management
With Management
Faster access to real world clinical and financial visibility
Pro-active management that validates optimal clinical and financial outcomes
Opportunity of 1-8 times ROI
201x y

8. Next Steps
This product/service is contained in the HR Specialty Products & Services Catalogue™
Operational level details about this particular service provider can be obtained in conference with the vendor
The HR Mining &Distribution Co. is an independent and contracted representative of the vendor
Upon your request, we will arrange for an introduction that can range from a simple, quick conference call to a services overview / system demo
Tom Ference (Chicagoland area) or
Thank you for your potential interest in this fresh thinking