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Rebate or Direct Purchase: What a PBM Can Do for Your State’s ADAP

Rebate or Direct Purchase: What a PBM Can Do for Your State’s ADAP. Presented By: Sophia J. Byndloss, President. Presentation Agenda. Let’s Understand PBMs Overview of Traditional PBM Services What a PBM Can Do for You Rebate State Direct Purchase State Ramsell’s Experience With ADAPs

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Rebate or Direct Purchase: What a PBM Can Do for Your State’s ADAP

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  1. Rebate or Direct Purchase: What a PBM Can Do for Your State’s ADAP Presented By: Sophia J. Byndloss, President

  2. Presentation Agenda • Let’s Understand PBMs • Overview of Traditional PBM Services • What a PBM Can Do for You • Rebate State • Direct Purchase State • Ramsell’s Experience With ADAPs • Questions Our heart is in public health.™

  3. Understanding PBMs • PBM Defined • A pharmacy benefits manager (PBM) is a third party administrator of prescription drug programs. • Responsible for the processing and payment of prescription drugs • PBM Structure • Part of a larger pharmacy or separate entities Our heart is in public health.™

  4. Formulary Management Formulary Development Formulary Maintenance Rebate Administration Pharmacy Network Clinical Services P&T Committee Prior Authorization Customer/Member Support Claims Adjudication Reporting Traditional PBM Services Our heart is in public health.™

  5. Traditional PBM Services • PBM Business Model • Traditional “spread pricing” • Administrative fees (i.e. per member or per claim, service) • Depend on revenues from pharmacy Our heart is in public health.™

  6. ADAP Saying… • “Once you’ve seen one ADAP, you’ve seen one ADAP.” Our heart is in public health.™

  7. PBMs and Rebate States • Pharmacy Network Management • Claims Adjudication • Formulary Management • Clinical Services • Reporting Our heart is in public health.™

  8. PBMs and Direct Purchase States • Pharmacy Network Management • Claims Adjudication • Clinical Services • Reporting Our heart is in public health.™

  9. Ramsell’s ADAP Experience • Contractor for California ADAP since 1997 providing PBM+ services • Traditional PBM services • Enrollment and Eligibility management • Cost containment strategy development and implementation • Payer of last resort (coordination of benefits) claims management • CMS data exchange administration Our heart is in public health.™

  10. Ramsell’s ADAP Experience • Contractor for California ADAP since 1997 providing PBM+ services • Clinical services • Collaboration in ADAP program administration • Reporting • Contractor for California County ADAP 1992 - 1997 providing PBM+ services Our heart is in public health.™

  11. Ramsell’s ADAP Experience • Contractor for Washington ADAP since 2001 providing PBM services • Traditional PBM services Our heart is in public health.™

  12. Ramsell’s ADAP Experience • Contractor for Flowers Heritage Foundation 2006 and 2008 for Montana Bridge the Gap (ADAP waitlist clients) • Pharmacy network management • Claims adjudication • Reporting Our heart is in public health.™

  13. Ramsell’s ADAP Experience • Partner of ADAP community • Developed tools for ADAP management • ADAP Management System Our heart is in public health.™

  14. Questions Our heart is in public health.™

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