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1 January 5, 2014 ©Copyright 2010 Jacqueline Madrigal Benefits Manager
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2 January 5, 2014 ©Copyright 2010
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3 January 5, 2014 ©Copyright 2010
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8 January 5, 2014 ©Copyright 2010 Self Funding Allows An Employer The Advantage Of Forecasting Claims
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9 January 5, 2014 ©Copyright 2010 Understanding Your Population (Being Plugged In)
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10 January 5, 2014 ©Copyright 2010 Know The Demographics Of Your Employees: Ethnicity Generation within the United States Age Range Level of Education
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19 January 5, 2014 ©Copyright 2010 Case Study Specialty Moving Lupron ® Lupron ® per claim costs dropped 60% by moving to prescription benefit Prescription Benefit Results: Lupron originally billed through physicians office at cost of $3,000 per claim Partners Rx moved Lupron to prescription benefit, saving $1,800 per claim Lupron® costs: Prescription benefit $1,200 Lupron ® costs: Medical benefit $3,000
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20 January 5, 2014 ©Copyright 2010 Case Study Over The Counter Tier Zero benefit Ulcer medication per claim costs dropped 87% by moving to Tier Zero OTC prescription benefit Prescription Benefit Results: Ulcer medications originally billed at cost of $165 avg per claim Partners Rx implemented Tier Zero prescription benefit, saving $143 per claim Ulcer medication per claim avg. costs after moving to Tier Zero benefit $22 Typical ulcer medication costs per claim avg. $165
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21 January 5, 2014 ©Copyright 2010 My goal… Minimizing my exposure, by understanding my population. Jacqueline Madrigal, Benefits Manager American Apparel
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22 January 5, 2014 ©Copyright 2010 Being Connected (Insight )
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23 January 5, 2014 ©Copyright 2010 American Apparel Medical Plan Benefits Covered Services EPOPPO In- NetworkOut-of-Network SUMMARY OF SERVICES Physician Visit$10 copay$15 copay30% Specialist Visit$10 copay$15 copay30% Diagnostic Testsno charge10%30% Laboratory and X-Ray Servicesno charge$15 copay30% Inpatient Hospitalizationno charge10%30% Outpatient Surgery$10 copay10%30% Emergency Room Visit$100.00 Urgent Care Visit$10 copay$15 copay30% Ambulance Services$50 copay10% Wellness Benefitsno charge$15 copayNo Coverage PRESCRIPTION DRUGS Generic$10 copay No Coverage Preferred Brand$25 copay No Coverage Non-Preferred Brand$40 copay No Coverage Mail Order2x copay No Coverage This is only an outline of benefits please see the Benefits Summary for a complete description of coverage.
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24 January 5, 2014 ©Copyright 2010 Food Vendors
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25 January 5, 2014 ©Copyright 2010 How Do I Measure Success? Generics 78% Running Below Expected Healthier and Happier Workforce
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26 January 5, 2014 ©Copyright 2010 Comprehensive Clinical Approach Improving Member Care Reduce Gaps in Care Provide Relevant Education Improve Adherence Maximize Safety Targeted patient-specific reports and education to prescribers and members: ACEI/ARB use Statin therapy Asthma management Migraine prevention Prescriber Outreaches: Educational information Leading industry guidelines Member Outreaches: Insightful information on general health topics: pain, sleep, allergy, cholesterol management, appropriate antibiotic use and maximizing generic utilization Prescriber Outreaches: Drug Interaction Alert Program Geriatric Monitor Program Narcotic Drug Utilization Review Program Prescriber Outreaches: Targeted educational mailings on such topics as depression and cholesterol disorders Member Outreaches: Targeted educational mailings on the importance of medication compliance Phone call reminders for late refills
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27 January 5, 2014 ©Copyright 2010 - Prior Authorization - Step Therapy Edit - Clinical Outreaches – Provider & Member - Quantity Limit Program - Dose Optimization Program - Brand to Generics Program - Formulary Management - Provider & Member Education - Low Total Cost Formulary - Generic Strategies - Network/MAC - Rebates Result: Lower Ingredient Cost Per Day Targeted Management Programs UtilizationQuantity Per RxNew Drug MixCost Per Unit
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28 January 5, 2014 ©Copyright 2010
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29 January 5, 2014 ©Copyright 2010 Additional Helpful Hints 1.TPA - Weekly or Bi-Weekly Claims Run 2.TPA - Request Mid-Week Claims Run: i.e. Receive report on Wednesday and Fund the following Tuesday 3.TPA -Strong working relationship with Case Manager /Nurse Manager 4.Request from PBM-Quarterly Reports: 1.Top 100 Drugs by Use and by Total Rx 2.Top 100 Drugs by Use and Amt Paid
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30 January 5, 2014 ©Copyright 2010 Q & A
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