Prescription Benefit Management
Prescription Drug Card Program —On-Going Plan Management
Formulary Management
Universal Rx has an independent third party clinical pharmacy team that develops the formulary and manufacturer contracts on its behalf. The reason for a neutral third party is to ensure each client and their interests and goals remain the top priority instead of rebates being the number one interest of the Prescription Benefit Manager and/or Mail Order Company.
For example, most of the leading PBM’s control their own formulary and mail order facilities. By doing this, they control the formulary and what is preferred and also what is sold at their mail order profit center.
This in no way benefits the client or their members. Often times more expensive drugs are included in the formulary as preferred drugs in order to boost profits through the PBM’s.
Plan Cost Results
At Universal Rx our third party clinical team is looking out for our client and their costs and can focus solely on this goal instead of other underlying profit center interests. As a result, our clients see lower Net/Net costs than our competitors.
"Net/Net" is the price of drugs per therapeutic class after discounts and rebates.
The goal is simply stated: Empower plan members to purchase the lowest priced and most proven drugs in each therapeutic class, ultimately achieving lower cost to the plan and their members. This works and we have the data to prove it. Please compare our trend factors against our competitors and you will see for yourself.
Formulary Management — Additional Information
Purpose of a Formulary
There are thousands of prescription medications available in today’s marketplace. A great number of these products have similar therapeutic uses and strengths; yet there are often large cost differences between them.
Formulary Management involves directing physicians and members to use recommended lower cost generic drugs that have the same or similar therapeutic outcomes.
The effective use of generic drugs within a formulary can have a significant impact on pharmacy program costs.
Benefits of a Formulary
Universal Rx offers clients flexibility in designing a generic substitution program that will achieve optimum savings while ensuring quality of care. Our clients work with us to define a custom formulary to meet the needs of their members and providers to help reduce total drug spending.
As part of formulary administration, Universal Rx provides clinical drug evaluations, economic evaluations of therapeutic alternatives, clinical recommendations, and communication of programs to clients.
The Universal Rx clinical pharmacy team has assembled a preferred drug listing that ensures plan participants receive the highest quality medications at the lowest possible prices. Our clinical pharmacy team evaluates FDA approved drugs based on cost-effectiveness, efficacy, quality and safety. This preferred drug listing, or Formulary, is regularly monitored and updated.
Understanding and Choosing the Right Formulary
There are two standard formulary options available; the Outcomes Formulary and the Focus Formulary. Each is based on a foundation of clinical review, practical application and value assessment.
The Pharmacy and Therapeutics (P&T) Committee reviews therapeutic classes and individual drugs for clinical appropriateness and practical application. Based on clinical evaluation and financial considerations, optimum formulary options are identified and incorporated into the standard formularies.
Both formulary options are considered “open” but the plan design for member co-payment determines the co-payment tier assignment for different medicines.
The Outcomes Formulary
The Outcomes Formulary provides maximum access to generic medications and a broad selection of Tier 2 brand drugs. The objective of the Outcomes formulary is to reduce barriers to necessary medications and to control costs through the application of patient-centered clinical programs and discount acquisition.
The Focus Formulary
The Focus Formulary provides access to a set of “best value” medications. The objective of the Focus formulary is to offer a clinically sound pharmacy benefit while controlling costs through product selection, clinical programs and discount acquisition.
Consultation and support necessary to determine the best possible formulary approach based on the client’s unique benefit design, utilization controls and formulary objectives.
Generic Utilization Initiatives
The Universal Rx Formulary Management program involves directing physicians and members to use recommended lower cost generic drugs that have the same or similar therapeutic outcomes.
The effective use of generic drugs within a formulary can have a significant impact on pharmacy program costs. Universal Rx offers clients flexibility in designing a generic substitution program that will achieve optimum savings while ensuring quality of care. Our clients work with us to define a custom formulary to meet the needs of their members and providers to help reduce total drug spending.
As part of formulary administration, we provide clinical drug evaluations, economic evaluations of therapeutic alternatives, clinical recommendations, and communication of programs to clients.
The Universal Rx clinical pharmacy team has assembled a preferred drug listing that ensures plan participants receive the highest quality medications at the lowest possible prices. Our clinical pharmacy team evaluates FDA approved drugs based on cost-effectiveness, efficacy, quality and safety. This preferred drug listing, or Formulary, is regularly monitored and updated.
Generic Mandates
In addition to the Universal Rx Formulary Management program, we also offer clients the option to place a “generic mandate” on their plan design. This can be set up 2 ways:
- When a member attempts to purchase a brand when a generic is available the claim will reject; OR,
- When a member attempts to purchase a brand when a generic is available the claim returns a co-payment in which the member pays their normal brand co-payment plus the difference between what the brand costs versus what the generic would have cost.
Preferred Rx
The use of Brand (or higher cost Tier 3) medications is major factor in the increasing costs of prescription drugs. Universal Rx recognizes this problem and has developed a program that focuses on steering members toward a more cost-effective method.
Although Tier 3 medications are usually a covered item, often plan members use these medications only because they are unaware that alternatives are available. Universal Rx utilizes innovative reporting to identify members who are currently utilizing a high cost prescription drug with comparable generics available. Universal Rx then contacts both the member and the member's prescribing physician to provide them a lower cost alternative medication option.
This program has helped boost clients’ savings tremendously. This value-added service encourages patients and doctors to be proactive in maintaining a level of responsibility to the plan. The member and the plan will both save money through the Preferred Rx program.
Most plans today utilize the tiered co-payment structure. For example:
20%+$15 |
Tier 3 - Highest Cost Brand Name Drugs |
20% |
Tier 2 - Highest Cost Generic & Lower Cost Preferred Brand Name Drugs |
10% |
Tier 1 - Generic Drugs and Selected Low Cost Brand Name Drugs |
Tiered co-payment structures provide cost savings incentives to plan members to always select the least expensive medication while still providing coverage on brand name drugs; however, only the plan member contributes more on these brand name drugs.
A tiered co-payment structure also affords Universal Rx the opportunity to offer our Preferred Rx program.
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Universal Rx • 710 3rd Street • Roanoke, VA 24016 • Phone 540-777-7179 • Fax 540-777-7184 • Email urx@universalrx.com
