If your Drug Benefit program is not an online process, you are vulnerable to benefit expense waste that can reach 30%.

Pharmacy Benefit Management systems are designed to optimize controllable items but, more importantly, intercept and minimize the effect of issues that are known to be uncontrollable when using old-fashioned retrospective systems (no online, real-time processing exists).

ONLY ONLINE DRUG BENEFIT PROGRAMS SURVIVE & THRIVE

      Experience has shown, in retrospective (off-line) systems, that it is impossible to intercept most forms of fraud and inappropriate dispensing.  The  free government benefit programs of the EU in the late 1980s and 1990s experienced great waste of important tax money by excesses approaching 30% equivalent to billions of dollars.

      Absent pre-dispensing verification of eligibility and Rx appropriateness, fraud and abuse will grow exponentially as more and more violators discover the ease of duping the system.

     In the 1980s ATM and credit card techniques pioneered online validation of credit worthiness before dispensing any funds or credit. Insurance companies copied the bank solution by devising similar online systems.  Indemnity benefit programs were abandoned almost immediately once the "PBM" online systems were introduced.

     Today there is little disagreement about  the value of surveillance of eligibility in advance of dispensing a prescription. Eventually the technology led to online cost containment strategies that were even of greater value in reducing benefit costs. 

    The TeleCLAIM system, after 20 years of incremental  trial and error improvements, implemented a variety of effective cost containment features that squeezed another 10% to15% of cost reductions.

    These reductions came about by influencing substitutions of Generics, catching dispensing requests in advance of expiration of the previous days-supply, voiding prescriptions by Specialists that are not common to their practice, and many other reasonable restrictions intercepting dispensing until a manual review.

     The Generic substitution of Brand drugs alone  resulted in major reductions of Benefit costs. Today Generics are commonplace and utilization surpasses Brands as the preferred drug.

       Another view of the impact of wanton waste is to consider the funds it steals from other medical budget categories when balancing a fixed or limited annual medical budget.

   One major aspect of runaway expenditures is the inexorable escalation resulting from the annual introduction of new drugs that add to the medical marketplace of prescribed pharmaceuticals.

   The controls available from today's PBM online, real-time systems, screen eligibility, the best of prescribed drugs, correct dosages, incentives for accepting Generics in lieu of Brand drugs, imposing reasonable limitations of days-supply, and intercepting requested refills that were too early versus the prior refill expectation of duration.

    In essence, real-time, online dispensing is as obvious a requirement for controlling costs as the credit card is to the banking industry. The purveyors of credit cards could never endure the potential fraudulent losses if they had not pioneered the online, real-time, instantaneous processing of a credit card transaction directly to the purchaser’s available funds or their positive credit standing.

    In summary, the benefits of a PBM Internet accessable adjudication system are easily justified by the substantial savings provided by controls without interfering with therapeutic efficacy.

    These assured savings, derived by minimizing increasing levels of abuse, overshadow by a very large percentage, the relatively small cost of implementing the Internet-delivered PBM solution. The PBM system cost is estimated to be less than 3% of the minimized drug product costs.

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