Avia Partners provides unique full service prescription benefit management services that enhance our clients' ability to manage costs associated with their prescription benefit. We develop comprehensive, tailor-made drug benefit programs to meet the needs of clients and their beneficiaries.
The Avia Partners' on-line system confirms eligibility and assists the pharmacist in monitoring on-going drug therapy through the use of the "Concurrent Drug Utilization Review" (DUR) program. We have expanded our services for covered members to include prescription card development, enhanced network access, enrollment maintenance, enhanced management reports, and a mail order option.
Customer Service
Our mission is to provide unparalleled customer service to our members, clients and providers.
Management Reporting
In order to facilitate proper plan management, it is imperative that the client receive reports to monitor costs. Avia Partners provides monthly executive summary reports to illustrate utilization, generic utilization, average costs, as well as the utilization and cost by classification and drug. These tools are designed to assist our clients in understanding the practicalities of their drug benefit.
Formulary
Avia Partners' formularies are designed to promote product selection by physicians by making available therapeutic guidelines and cost effectiveness data. Formulary customization is available to meet the specific needs of the client while maintaining the therapeutic integrity of the drug benefit.
On-line Claims Processing
Avia Partners' system supports on-line applications for enrollment and eligibility file maintenance, card production, plan definition, claim processing, and customer service inquiries. Batch applications support the maintenance of the drug data base, data interfaces, check processing, and reporting. Each prescription claim is processed through a minimum of eight edits before the claim is accepted.
Performance Guarantee
Avia Partners guarantees its performance under a Prescription Service Agreement.
Mail Order
Avia Partners' Mail Order Prescription Program may provide a convenient alternative for some plan beneficiaries. Member utilization of mail order is integrated into the client reports, in order to provide comprehensive integrity and ease of administration. Avia Partners' mail order option is designed to enhance patient convenience while preserving the pharmacist-patient relationship.
Specialty Drugs
Specialty medications are dramatically changing the healthcare landscape. While offering great potential for managing diseases, these medications also present significant care management and cost challenges for plan sponsors. As specialty costs continue to climb, Avia Partners recognize that today's fractured management approach must be addressed. Trying to control specialty drug spend through traditional medical and pharmacy plans inhibits effective management in both areas. Through a specialty drug offering, plan sponsors can work with physicians and patients to meet two principal goals, improved outcomes and managed costs.
Customized Plan Design
Avia Partners provides proven, cost-effective pharmacy benefit programs which maximize the availability of services to members while minimizing costs. Avia Partners can develop a custom plan design to meet the needs of each client.
Our professionals work with each client to determine coverage and copayment options that will establish the most cost-effective drug benefit program. Numerous design options are available, for example, variable copayments, individual or family deductibles, and stated limits on the total annual benefit per individual or family.
Avia Partners' freedom of choice philosophy offers flexibility in benefit design. We provide a standardized list of drug inclusions and exclusions from which a client may select coverage. The client may opt for virtually any drug class to be added or excluded.
Avia Partners assures the integrity of these flexible plan design parameters through the provision of timely and succinct management reports that enable clients to maintain economic control over their program.
Implementation -- Avia Partners will develop for each client an implementation schedule to ensure efficient plan start-up.
Implementation is client specific and depends upon the enrollment information and the complexity of the eligibility documentation and benefit design. The process usually takes a minimum of 30 days.
Eligibility
Covered members must be identified as eligible to receive services. Data required for eligibility may include: member name and date of birth, cardholder id and group identification number. The eligibility file format is provided to each client.
Personalized Identification Cards
Each covered member may receive a personalized identification card, if required under the client's plan design. Copays and deductibles, if any, are stated on the card. Differing copays for generic and brand name drugs can also be included to enhance cost containment by driving generic selection.
Drug Utilization Review (DUR)
The Avia Partners' point-of-sale system includes the following clinical modules:
This is a powerful system for monitoring, reviewing or auditing patient compliance.
Clinical Intervention Program (RetroDUR)
The main goal of the retrospective drug utilization review (RetroDUR) program is to improve healthcare services delivered to members. Cost savings are the by-product of this endeavor. Physicians are dramatically more receptive to educational interventions than cost reduction initiatives. RetroDUR programs not only improve healthcare delivery, but save large amounts of money as demonstrated through scientifically defensible methodologies.
The RetroDUR provides the following analysis:
Drug-drug interaction
Drug-disease interaction
Drug over-utilization
Drug under-utilization
Drug-pregnancy alert
Therapeutic duplication
Addictive substances
Drug-patient interaction
Drug-age interaction
Multiple physicians
Multiple pharmacies
Step Therapy Program
Step therapy is a program designed to encourage the use of therapeutically equivalent, lower-cost drugs (first-line therapy) before stepping up to medications that are more expensive (second-line therapy). It represents a progression toward tighter, more powerful trend-management tools. Step therapy involves real-time checks of the member's claims history. Step-therapy modules give plan sponsors the option of grandfathering or not grandfathering to generate significantly more savings. The growth in step-therapy programs is also being fueled by increasing numbers of therapeutically equivalent treatment alternatives available for many health conditions.
Prior Authorization Program
A select number of drugs are placed on the Prior Authorization (PA) drug list because the drugs have patient safety concerns, quantity limits, or extremely high cost.. The goal of the PA is to ensure medications are being appropriately prescribed and used. As part of the decision process to have the drug approved and dispensed, Avia Partners has developed specific criteria regarding the "standard indication" for use of the drug and quantity limits for each drug.
Dose Optimization Program
Avia Partners offers a dose optimization or dose consolidation program for selected medications. The purpose of the program is to change multiple dose medications to a single daily dose where appropriate.
Quantity Limits Program
Avia Partners offer a Quantity Limits Program option where some drugs are subject to quantity limits (QL) on the amount of the medication that a patient can receive (number of days' supply, quantity limits, frequency of refills, etc.). All Quantity Limit (QL) maximums are based on approved FDA dosing maximums.
No Cost Co-Pay Generic Program
Avia Partners No Cost Co-Pay program is an innovative solution to help plan sponsors and their members take advantage of the cost savings associated with generic drugs. This program illustrates a commitment to lowering clients' prescription-drug costs, while giving members access to the drugs they need.
Disease Management Program
Avia Partners Disease Management Programs focus on physician prescribing and patient compliance to maximize the health status of defined patient populations. Successful health management programs are developed and implemented in partnership with patients, physicians and pharmacists, because all of these individual stakeholders understand the value and relative contribution each brings to the program.
Avia Partners Advanced Disease Management program involves integration of client provided ICD-9 codes to target selected disease states, such as Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Congestive Heart Failure, and Allergic Rhinitis. Patient coaching is provided by Nurses trained in disease management.
Physician Intervention and Education
Physicians may be contacted to clarify indications for unusual drug therapy. When necessary, they are also notified regarding patients who may be seeing multiple prescribers. Avia Partners assists the physician in maximizing drug safety and cost effectiveness.
Special Reports By Request
The Avia Partners' on-line system confirms eligibility and assists the pharmacist in monitoring on-going drug therapy through the use of the "Concurrent Drug Utilization Review" (DUR) program. We have expanded our services for covered members to include prescription card development, enhanced network access, enrollment maintenance, enhanced management reports, and a mail order option.
Customer Service
Our mission is to provide unparalleled customer service to our members, clients and providers.
Management Reporting
In order to facilitate proper plan management, it is imperative that the client receive reports to monitor costs. Avia Partners provides monthly executive summary reports to illustrate utilization, generic utilization, average costs, as well as the utilization and cost by classification and drug. These tools are designed to assist our clients in understanding the practicalities of their drug benefit.
Formulary
Avia Partners' formularies are designed to promote product selection by physicians by making available therapeutic guidelines and cost effectiveness data. Formulary customization is available to meet the specific needs of the client while maintaining the therapeutic integrity of the drug benefit.
On-line Claims Processing
Avia Partners' system supports on-line applications for enrollment and eligibility file maintenance, card production, plan definition, claim processing, and customer service inquiries. Batch applications support the maintenance of the drug data base, data interfaces, check processing, and reporting. Each prescription claim is processed through a minimum of eight edits before the claim is accepted.
Performance Guarantee
Avia Partners guarantees its performance under a Prescription Service Agreement.
Mail Order
Avia Partners' Mail Order Prescription Program may provide a convenient alternative for some plan beneficiaries. Member utilization of mail order is integrated into the client reports, in order to provide comprehensive integrity and ease of administration. Avia Partners' mail order option is designed to enhance patient convenience while preserving the pharmacist-patient relationship.
Specialty Drugs
Specialty medications are dramatically changing the healthcare landscape. While offering great potential for managing diseases, these medications also present significant care management and cost challenges for plan sponsors. As specialty costs continue to climb, Avia Partners recognize that today's fractured management approach must be addressed. Trying to control specialty drug spend through traditional medical and pharmacy plans inhibits effective management in both areas. Through a specialty drug offering, plan sponsors can work with physicians and patients to meet two principal goals, improved outcomes and managed costs.
Customized Plan Design
Avia Partners provides proven, cost-effective pharmacy benefit programs which maximize the availability of services to members while minimizing costs. Avia Partners can develop a custom plan design to meet the needs of each client.
Our professionals work with each client to determine coverage and copayment options that will establish the most cost-effective drug benefit program. Numerous design options are available, for example, variable copayments, individual or family deductibles, and stated limits on the total annual benefit per individual or family.
Avia Partners' freedom of choice philosophy offers flexibility in benefit design. We provide a standardized list of drug inclusions and exclusions from which a client may select coverage. The client may opt for virtually any drug class to be added or excluded.
Avia Partners assures the integrity of these flexible plan design parameters through the provision of timely and succinct management reports that enable clients to maintain economic control over their program.
Implementation -- Avia Partners will develop for each client an implementation schedule to ensure efficient plan start-up.
Implementation is client specific and depends upon the enrollment information and the complexity of the eligibility documentation and benefit design. The process usually takes a minimum of 30 days.
Eligibility
Covered members must be identified as eligible to receive services. Data required for eligibility may include: member name and date of birth, cardholder id and group identification number. The eligibility file format is provided to each client.
Personalized Identification Cards
Each covered member may receive a personalized identification card, if required under the client's plan design. Copays and deductibles, if any, are stated on the card. Differing copays for generic and brand name drugs can also be included to enhance cost containment by driving generic selection.
Drug Utilization Review (DUR)
The Avia Partners' point-of-sale system includes the following clinical modules:
| • | Drug Interactions - This module screens each new prescription against the patient's current medications on an ingredient basis. If an interaction surpasses set thresholds, a warning message, stating the drug or drugs involved, level of interaction and effect code, is transmitted to the pharmacist. | ||||||
| • | Duplicate Drug Therapy - Each prescription (new and refill) is screened for duplication, defined as the same generic entity and same dosage form, against all other active prescriptions on the patient's drug profile. A warning message is transmitted if a duplicate is found. | ||||||
| • | Therapeutic Overlap - Each new prescription is screened against all other active prescriptions in the drug profile. Therapeutic overlap is defined as drugs in the same class with the same systemic/non-systemic indicator. A warning message is transmitted if any overlap is found. | ||||||
| • | Age Precautions - A warning is transmitted when the prescription submitted should not be used in the patient's age group, which is determined by the patient's date of birth. | ||||||
| • | Compliance Monitoring - Refills for selected chronic drugs are monitored and a warning message is transmitted to the pharmacist when the refill is either too early or too late. | ||||||
| • | Prescribing
Limits - An appropriate warning message is transmitted if any of the following limitations occur:
|
This is a powerful system for monitoring, reviewing or auditing patient compliance.
Clinical Intervention Program (RetroDUR)
The main goal of the retrospective drug utilization review (RetroDUR) program is to improve healthcare services delivered to members. Cost savings are the by-product of this endeavor. Physicians are dramatically more receptive to educational interventions than cost reduction initiatives. RetroDUR programs not only improve healthcare delivery, but save large amounts of money as demonstrated through scientifically defensible methodologies.
The RetroDUR provides the following analysis:
Drug-drug interaction
Drug-disease interaction
Drug over-utilization
Drug under-utilization
Drug-pregnancy alert
Therapeutic duplication
Addictive substances
Drug-patient interaction
Drug-age interaction
Multiple physicians
Multiple pharmacies
Step Therapy Program
Step therapy is a program designed to encourage the use of therapeutically equivalent, lower-cost drugs (first-line therapy) before stepping up to medications that are more expensive (second-line therapy). It represents a progression toward tighter, more powerful trend-management tools. Step therapy involves real-time checks of the member's claims history. Step-therapy modules give plan sponsors the option of grandfathering or not grandfathering to generate significantly more savings. The growth in step-therapy programs is also being fueled by increasing numbers of therapeutically equivalent treatment alternatives available for many health conditions.
Prior Authorization Program
A select number of drugs are placed on the Prior Authorization (PA) drug list because the drugs have patient safety concerns, quantity limits, or extremely high cost.. The goal of the PA is to ensure medications are being appropriately prescribed and used. As part of the decision process to have the drug approved and dispensed, Avia Partners has developed specific criteria regarding the "standard indication" for use of the drug and quantity limits for each drug.
Dose Optimization Program
Avia Partners offers a dose optimization or dose consolidation program for selected medications. The purpose of the program is to change multiple dose medications to a single daily dose where appropriate.
Quantity Limits Program
Avia Partners offer a Quantity Limits Program option where some drugs are subject to quantity limits (QL) on the amount of the medication that a patient can receive (number of days' supply, quantity limits, frequency of refills, etc.). All Quantity Limit (QL) maximums are based on approved FDA dosing maximums.
No Cost Co-Pay Generic Program
Avia Partners No Cost Co-Pay program is an innovative solution to help plan sponsors and their members take advantage of the cost savings associated with generic drugs. This program illustrates a commitment to lowering clients' prescription-drug costs, while giving members access to the drugs they need.
Disease Management Program
Avia Partners Disease Management Programs focus on physician prescribing and patient compliance to maximize the health status of defined patient populations. Successful health management programs are developed and implemented in partnership with patients, physicians and pharmacists, because all of these individual stakeholders understand the value and relative contribution each brings to the program.
Avia Partners Advanced Disease Management program involves integration of client provided ICD-9 codes to target selected disease states, such as Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, Congestive Heart Failure, and Allergic Rhinitis. Patient coaching is provided by Nurses trained in disease management.
Physician Intervention and Education
Physicians may be contacted to clarify indications for unusual drug therapy. When necessary, they are also notified regarding patients who may be seeing multiple prescribers. Avia Partners assists the physician in maximizing drug safety and cost effectiveness.
Special Reports By Request
| • | Claim Summary by Drug |
| • | Claim Summary by Pharmacy |
| • | Claim Summary by Prescriber |
| • | Claim Summary by Network |
| • | Claim Summary by Plan |
| • | Individual Cardholder Drug Utilization Audits |