Pharmacy Benefit Design
At PDMI, the high level of support we provide our clients in the areas of claims processing and benefit design is the backbone of our operation. We offer the comprehensive benefit support expected from a full-scale PBM at the price of a claims processor.
PDMI provides its clients with assistance in benefit plan design based on years of experience processing pharmacy claims. With this knowledge, PDMI has assisted a variety of clients with developing and maintaining their benefits. We work closely supporting clients' benefits departments to define, document and input plan information.
Indemnity, HMO, PPO, Medicare Part D/Medicaid, and self-insured benefit plan models are supported by system edits designed to achieve specific plan goals.
Achieving this flexibility while enhancing a system that remains reliable, understandable and predictable is facilitated by providing a "cafeteria" approach with a wide array of optional claims edits.
Our state-of-the-art proprietary software gives us the flexibility we need to customize our system for each client. In effect, each client has its own customized claims processing program.
Our areas of customization are virtually limitless, but some of the common areas include the following:
- Formularies – PDMI can implement or modify your current formularies, or we can help you customize new ones. We can handle multiple formularies, and we place no limitations on any of them. We will assist you with formulary compliance: at your request, we can run reports to show the compliance or non-compliance of the plan's members; in addition, we can implement high copays for non-formulary drugs or lower copays for formulary drugs.
- Pharmacy Networks – PDMI can utilize the client's current retail pharmacy network as the preferred network with our retail pharmacy network as a wraparound network. If the client chooses to utilize PDMI as its preferred network, we have more than 60,000 participating chain and independent retail pharmacies nationwide. Currently all major retail pharmacy chains participate in our network.
- Mail Order Service – PDMI holds no ownership stake in any mail order facility. We can interface with a mail order service (or concurrently with multiple mail order services) of the client's choosing. We can also recommend a mail order service whose goals are most closely aligned with those of the plan.
- Copay Structures – To date, we have been able to accommodate all copay requests, including multi-tiered benefits. Examples of plan designs (with various copays) we implement include:
- Copays based on the greater of a dollar amount or percentage of cost basis – PDMI has the ability to apply minimum or maximum copays. For example, if the percentage copay (the percentage of the drug cost that is the copay) is greater than the maximum amount, the maximum amount will apply. If the percentage copay is less than the minimum amount, the percentage copay will apply. Maximum and minimum amounts can only be fixed dollar amounts.
- Brand vs. generic copays by dollar differential – PDMI has the ability to differentiate brand vs. generic copays by dollar amount (e.g., brand drug's copay, $10; generic drug's copay, $5). PDMI also has the ability to charge "plus the difference" on products. "Plus the difference" can only be calculated if the brand has a generic available and there is a MAC price on the generic drug (e.g., the brand costs $40 and the generic costs $20; the $20 difference is added to the $10 brand copay and the member would pay $30 for the brand drug).
- Individual and family deductibles – PDMI can track deductibles three ways: individually, at the family level and in combination. We can also maintain different deductible periods (e.g., yearly, quarterly).
- Individual and family maximum(s) – PDMI can track maximums three ways: individually, at the family level and in combination. We can also maintain different maximum periods (e.g., yearly, quarterly).