This is the virtual TeleCLAIM Command
Center for controlling Drug Benefit costs.
“PlanBuilder” is the TeleCLAIM++ module used by the Administrator
of the PBM or Insurance user. It is a simple to use this facility to
create the “adjudication” algorithm to process all Rxs submitted
for approval, applying limitations and adjustable pricing.
(Adjudication is the vernacular for computations, limitations and
screening that the Sponsor imposes as the basis for the subsidy
benefit.)
This module creates an algorithm of a specific Benefit Plan, given a
unique ID, that gets manage a Plan for a Group of Insured members. (An
unlimited number of specific Plans may be used to customize as much as
a user may desire for targeted insurance premium Group categories.)
Slight variations to a basic Plan may be easily implemented. A cloning
feature is provided so that small modifications are inserted for
specialized changes made to another Plan. (e.g. - a plan for females
may have many common factors with one created for senior citizen
females with an exclusion of contraceptive drugs .)
The PlanBuilder module has the following order of screening and
calculation steps of the adjudication process:
- Exclusions - Absolute
exclusion of drugs by entire class categories (e.g. birth control
drugs) and optional inclusion of a designated Formulary by an ID
literal.
- Ingredient Costs - Several
variations of provider reimbursement computations for the ordered
drug. The variations have parameters for Brand vs. Generic; for
high priced vs. low priced drugs; discounts for Preferred vs.
Regular Pharmacies;
- DAW - (Dispense As Written
parameters) is a screening that affects Ingredient Cost as it
pertains to Brands vs. Generic selections and options that were
available.
- Dispense Fee – The flat
amount payable to the Provider for the dispensing service of an
Rx. It may allow different amounts for Brands vs. Generics or for
Preferred v. Regular pharmacies.
- Co-Pay – Computation of
Co-Pay amount paid to the Provider Pharmacy by the buyer for an
individual Rx. This amount offsets the total payable to the
Provider and reimbursable by the Benefit Sponsor to the PBM.
- PBM Administration Fees -
The PBM’s basic charges to its Benefit Sponsor client are
defined here for the (a) Transaction Fee rate; (b) AWP price
discount (%) of Rx Ingredient Cost; (c) Dispensing Fee rate.
- Dispensing Limits – The
quantities allowed based on duration of supply for various
conditions.
- Quantity Limits –
Quantities (units, Ml or Gms) are designated as maximums with
variations of other conditions.
- System Edits & Information
– Specific conditions (e.g. –DOB, etc.) optionally designated
to accept or reject a claim.
- Deductible/Maximum Benefit
Limits – This section imposes either or both of the
available limiting conditions of the Plan. Deductible Limit
applies to the first amounts excluded from coverage. The Maximum
amount is the Limit beyond which coverage shall be denied.
|
