FORMULARY PERFORMANCE

Formulary decisions are reviewed by HealthLinX (HLX) for the lowest net cost drug in a therapeutic class.  The prescription benefit manager (PBM) may have financial incentives to increase rebates by using the most expensive drug available.  This will often not be the best financial situation for the plan.  HLX will assist the plan in navigating through the pitfalls of the formulary/rebate system.

 

MAC COMPARISONS

Maximum Allowable Cost (MAC) is set by the PBM to cover generic drugs from several manufacturers with one reimbursement rate.  This eliminates the AWP’s, which are arbitrarily set by the manufacturer, from impacting the cost of the drug.  HLX will provide an analysis of how your PBM’s MAC compares to the Federal HCFA/CMS MAC to determine any potential up charging to the plan. 

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FRAUD AND ABUSE MANAGEMENT

Many of our plans suffer from abuse of narcotics and fraudulent receipt of prescriptions.  HLX has several proprietary systems to identify and track members, physicians and pharmacies who demonstrate activities which are outside of the norms set by your specific group.

 

DENIAL OF SERVICE REVIEW

When a member is denied a drug, HLX can review the circumstances and make a professional, informed, decision on the coverage for that member.  Because of our experience in the industry, all components (not just price or benefit design) can be weighed to make a written recommendation of coverage to the plan.