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

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Rebate or Direct Purchase What a PBM Can Do
for Your States ADAP

• Presented By
• Sophia J. Byndloss, President

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Presentation Agenda

• Lets Understand PBMs
• Overview of Traditional PBM Services
• What a PBM Can Do for You
• Rebate State
• Direct Purchase State
• Ramsells Experience With ADAPs
• Questions

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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

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Traditional PBM Services

• Formulary Management
• Formulary Development
• Formulary Maintenance
• Rebate Administration
• Pharmacy Network
• Clinical Services
• PT Committee
• Prior Authorization

• Customer/Member Support
• Claims Adjudication
• Reporting

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Traditional PBM Services

• PBM Business Model
• Traditional spread pricing
• Administrative fees (i.e. per member or per
  claim, service)
• Depend on revenues from pharmacy

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ADAP Saying

• Once youve seen one ADAP, youve seen one ADAP.

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PBMs and Rebate States

• Pharmacy Network Management
• Claims Adjudication
• Formulary Management
• Clinical Services
• Reporting

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PBMs and Direct Purchase States

• Pharmacy Network Management
• Claims Adjudication
• Clinical Services
• Reporting

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Ramsells 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

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Ramsells 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

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Ramsells ADAP Experience

• Contractor for Washington ADAP since 2001
  providing PBM services
• Traditional PBM services

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Ramsells ADAP Experience

• Contractor for Flowers Heritage Foundation 2006
  and 2008 for Montana Bridge the Gap (ADAP
  waitlist clients)
• Pharmacy network management
• Claims adjudication
• Reporting

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Ramsells ADAP Experience

• Partner of ADAP community
• Developed tools for ADAP management
• ADAP Management System

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Questions