Pharmacy Benefits Management

A Next-Generation Solution

Streamlines the entire claims process using robust and intuitive technology tools designed with input from experienced claims professionals
Maximizes savings through aggressive pricing and optimal cost containment tactics
Enables strategic decisions by leveraging artificial intelligence to analyze data and provide actionable insights
Drives better health outcomes with targeted clinical guidance that automates decisions when appropriate - and escalates decisions when necessary
Ensures easy access to care at minimal cost with a best-in-class pharmacy network and unsurpassed penetration strategies
Builds confidence and trust with complete transparency into pharmacy prices and cost drivers

Next-Generation Pharmacy Management

Current Rx Concerns in Workers’ Comp

Workers’ comp pharmacy management continues to evolve dramatically. Industry-wide reductions in opioid use and costs have given way to more nuanced – but still concerning – prescribing trends and cost drivers that present challenges for today’s payers.

Healthesystems is addressing the top priorities of today’s payers including:

1.

Transparency:

Providing a better definition of, and visibility into, what you pay
2.

Claims Complexity:

Identifying risks that drive claim complexity and enabling early engagement
3.

Automation & Efficiency :

Building more robust automation capabilities into the claims process
4.

User Experience:

Delivering intuitive solutions that provide an optimal experience for claims teams’ and patients

We stand apart from the industry by providing exceptional pharmacy program management through our:

Transparency

42%

of payers are concerned about lack of visibility into medical and drug prices

Transparency is essential to understanding the economic drivers within your workers’ comp pharmacy program. Lift­ing the shroud that often cloaks pricing and program performance details provides a more complete picture of cost dynamics throughout the pharmacy supply chain.
We provide a clear view into the economics and ROI of your pharmacy program, including:

Rebates and their impact

How drugs are classified as brand or generic

Whether drugs are priced according to their official designation

Transparent data insights at the program, population, and patient levels

Data & Analytics

10%

of claims = 60% of pharmacy costs

The fragmented workers’ comp system isolates relevant information and obscures a holistic view of the patient, creating roadblocks to effectively assessing and managing injured worker populations and causing claims to unexpectedly escalate.
We capture, process, and analyze myriad disconnected facts and turn data into the visual, actionable information needed to glean insights and guide important clinical and operational decisions to help you:

Account for customer and population specific needs

Inform therapy decisions and intervention opportunities

Monitor trends and make clinical or operational adjustments

Drive quality improvement and program effectiveness

Clinical Guidance

67%

of medical program managers want better solutions to support front-line claims decisions

Treating workers’ comp patients has become more complex. Comorbidities, psychosocial issues, and decreasing access to affordable care are impacting worker health and can lead to over-reliance on potentially harmful medications.
Our full-service clinical program stands apart from the industry with pharmacology and occupational health expertise embedded in our tools and workflows, along with high-touch services including:

Dedicated and customized program consultation

Formulary design and management

Population and patient risk monitoring

Clinical interventions

Ongoing education

Clinical resource support

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Technology & Automation

40%

of claims professionals report using inadequate/outdated claims processing systems

Our integrated technology platform, Verticē, provides advanced tools for managing all Rx activity and a central connection point for communicating across the workers’ comp healthcare ecosystem that :

Automates workflows to maximize operational efficiencies

Provides an exceptional user experience for claims professionals

Drives real-time clinical information into the decision-making process

Positively influences patient outcomes

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Pharmacy Network

61%

of industry stakeholders want to increase use of network providers

Our best-in-class network design provides a nationwide network of pharmacies, customizable mail order options, third-party bill management, and unsurpassed network penetration strategies that result in:

Easy access to care

Reduced costs

Higher network penetration rates

Better patient experience

Less work for claims professionals

More effective drug utilization management

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Key Benefits of Healthesystems Pharmacy Program

Identifies risks and reduces use of controlled substances and other concerning drugs
Simplifies claims processing and improves user and patient experience
Utilizes powerful data and analytic models to automate processes and inform decisions
Ensures appropriate and effective drug utilization
Minimizes out of network activity
Reduces physician dispensing, private-label and compound medications
Enables customized program strategies
Allows clear visibility into how pricing is structured and applied

PBM Resources

HIV Medications: New Approval and News of Discontinuations

Sunlenca approved for treatment-resistant populations, but a number of other drugs will cease production, some of which are included in PEP guidelines.

Jan 2023

The Triple Threat of Tobacco Use on Employer, Clinical, and Medication Complexity

Tobacco use as a complicating factor in workplace injury and recovery.

Jan 2023

Study Explores Potential Association Between Occupational Inhalants and Rheumatoid Arthritis

Exposure to various gases and vapors has been associated with autoimmune disease

Jan 2023

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Gain nuanced insight into your Rx drug activity, trends and opportunities through our complimentary consultative Rx e360 analysis.

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