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.”