Administration of Complex Drug Benefit Designs NCPDP
- Tiered Copay
- Proliferation of Prescription Drug Plans
- Drug Utilization Review – movement to perform concurrent reviews and not just reports.
- How to Administer Drug Benefit Limitations & Formularies?
Industry Needed a “Real Time” Drug Claim Transaction
- Verify Eligibility at Point-of-Sale
- Verify Plan Design
- Check for Early Refills, Drug Interactions, Therapeutic Duplication
- Lower Administrative Transaction Costs
- Improved Pharmacy Cash Flow
Advantages of Real Time Rx Claims Transaction
- Concurrent DUR and management possible.
- Technically, data can reside within health plan’s system within 24 hours.
- Early warning flag for upcoming medical claims.
- Could signal the beginning of an “episode of care.”