Five Reasons to Carve in Your Pharmacy Benefit Manager

Pharmacy spending represents a growing and significant portion of healthcare costs. That is why our preferred partner, OptumRx, provides services that help your members realize improved care, lower costs and a better overall experience. OptumRx is one of the largest pharmacy benefit management solutions, with access to more than 68,000 pharmacies nationwide, and serving more than 13.5 million members. Together, we’ll help your employees manage and save money on the prescriptions they need by addressing these five key aspects of drug spend.

Better Trend Management

Our experienced, multidisciplinary team of medical directors, pharmacists and clinicians work collaboratively and in conjunction with our independent Pharmacy and Therapeutics (P&T) Committee to meet this goal by managing PAI Lowest Net Cost Formulary and clinical programs with an eye toward positively impacting overall health care quality and cost. Our unified clinical management approach results in aligned incentives resulting in the highest quality health outcomes for you and your members. Members can feel good knowing that each medication has been reviewed for safety, effectiveness, clinical outcomes and cost.

We encourage our members to talk to their doctors about generic and preferred brand-name drugs that may be a good choice for them and also save them money. The drug lists that apply to our plans may vary.
Mail Service Pharmacy Program

Mail service pharmacy is a convenient and cost-effective way for members to order up to a 90-day supply of maintenance or long-term medication for delivery to their home, office or location of their choosing. Members will minimize trips to the pharmacy and save money on their prescriptions by using an order form or have their doctor call or fax the prescription to the pharmacy. Refills are made easy by ordering online, via the automated telephone services, or by calling Customer Service.
Clinical Bundle Program Differentiators

Medication Adherence Program
Our Medication Adherence Program leverages analytics and timely interventions to improve adherence. It supports outreach to the right members at the right time using the right approach: Identification of members who are at risk of poor adherence such as low-adherence rates and providing targeted timely interventions such as physician notifications.

Opioid Risk Management Solution

In keeping with the national effort to stem the tide of this epidemic, our opioid management program confronts all aspects of the opioid epidemic by addressing clinical opportunities and engaging consumers, prescribers and pharmacies across the entire care continuum and/or life count. The program consists of prevention and education, daily quantity limits specific to each covered opioid drug and prior authorization requirements for certain prescribing situations.

Retrospective Gaps in Care

The Retrospective Drug Utilization Review DUR program delivers incremental health care savings by closing gaps in medication therapy for treating chronic disease. Advanced analytics conduct medication evaluation of every claim to alert physicians to potential gaps in care.

Specialty Medical Benefit Management (SMBM)

Our specialty medical benefit management suite includes medical prior authorization, site of care steerage, and self-administered drug block. The prior authorization component seeks to apply consistency under the medical and pharmacy benefit, in prior authorizing certain specialty drugs across the benefit spectrum. The site of care process is to steer members on certain specialty drugs to appropriate, lower-cost sites of care such as infusion centers or the member’s home. The self-administered drug block program works to steer certain self-administered specialty drugs from being covered under the medical benefit to pharmacy benefit.
Drug Management Programs

The goal of our drug management programs is to provide members with a wide variety of prescription medications that are safe, effective and affordable. The programs below help ensure that members have access to the medications they need, while keeping costs down and adhering to the recommendations of the doctors, pharmacists and other experts who manage our pharmacy programs. To help plans control prescription drug spending, PAI pharmacy benefits offers the following drug management programs.

Prior Authorization
Quantity Limits
Step Therapy
Optum Specialty Pharmacy

Specialty drugs are used to treat chronic medical conditions and genetic diseases such as rheumatoid arthritis, osteoporosis, multiple sclerosis and cancer. These specialty drugs can average thousands of dollars per month, and the underlying medical condition can present unique challenges to patients. Optum Specialty Pharmacy can help alleviate the challenge of managing and living with a complex health condition, and is there to assist members every step of the way.

Pharmacists and patient care coordinators are available 24/7 to assist members with things such as:

Transferring member prescriptions to Optum Specialty Pharmacy
Helping members find affordable access medications
Refill reminders via text or phone call
Confidential and convenient delivery of specialty drugs at no additional change
Automatically filing claims and prior authorizations

Web Capabilities and Mobile App

We offer single sign on access to PAI Pharmacy Benefits at the member portal located on www.paisc.com. Members can also download the OptumRx Mobile App, which makes the online pharmacy experience available on-the-go. From their smartphone or tablet, members can:

Refill or renew a home delivery prescription
Transfer a retail prescription to home delivery
Find drug prices and lower-cost options
Review prescription order status
Locate a pharmacy

Members with PAI’s preferred pharmacy benefit coverage with OptumRx can use the drug cost estimator tool. For the most accurate and up-to-date information for all members, they can log into MyBenefitsManagerSM, then PAI Pharmacy Benefits.

Better Partnership
At PAI, we focus not just on managing drug costs, but also on helping clients understand how appropriate, cost effective prescription utilization can improve the health of their members. Our ultimate goal is to provide our customers with independent, unbiased pharmacy management solutions for improved quality of care, effective cost management, and higher member satisfaction. Our Pharmacy Management team is composed of highly trained pharmacists and industry experts. We couple this strength with the power of our PBM Center of Excellence team to give our customers access to size and scale and ultimately, a louder voice when navigating the complexities of a pharmacy benefit.