Prior Authorizations & Pre-Certification Reviews
Pro Pharma can review Specialty medications daily or on an “as needed” basis for Prior Authorization. Evaluations can also be an in-depth chart review for benefit approved indications and support for therapy for extraordinary circumstances
Managed Care & Pharmacy Expertise
We have been in Managed Care for many years and worked with a wide variety of Health Plans, Municipalities, Self-Insured Companies, and more. Pro Pharma customizes our approach for each client’s needs.
Customized Maximum Allowable Cost List (MAC List)
Pro Pharma’s Custom MAC List is transparent, updated frequently, accessible to all – and the savings go to the Payer and Patients. The MAC List sets generic pricing to be normative (cost plus) for both Plans and Pharmacies.
Audits - Current, Retrospective, & Compliance
Pharmacy Claims (Standard & Specialty Medications)
We call these Invoice Screens™ or current audit/analysis. Review of biweekly PBM pharmacy invoices for pre-adjudication claims can save you 7-11% in overall drug spend. Coupled with claims review, these screens can also focus on the providers, physicians and pharmacies responsible for rejected claims that did not meet contract requirements.
Integrating Pharmacy Claims & Medical Encounter Claims Retrospective
Pro Pharma analyzes pharmacy and medical encounter claims – identifying outliers and testing for cost, diagnosis, dose, utilization and clinical reviews. The outcomes include identifying claims that were paid for unapproved uses and paying specialty medication claims at a more favorable rate.
State & Federal Compliance
Pro Pharma performs State Compliance Audits for Health Plan Pharmacy Programs. The compliance audits reference applicable state regulatory code criteria. Both the Plan and the PBM are issued requests for documentation to support code compliance, delegation to the PBM, and summary bulleted information to help guide the audit.
Analytics - Financial
Fraud, Waste, & Abuse (FWA)
At Pro Pharma, we have strategies to identify the offenders (Fraud) and prevent Abuse and Waste – going beyond their PBM’s approach
Forecasting & Predictions
Our program is unique in that we Combine integrated data sets of pharmacy, medical, laboratory, eligibility, Workers' Compensation loss runs, etc. We use Artificial Intelligence (AI) data sets across multiple data formats using Pharmacy Benefit Management (PBM), Third Party Administrators (TPAs) and health plan data sets collected for over 20 years.
Management Reporting Central
A self-serve analytics tool with selections by client type, organizational role, report name, report category, or search function. Executives, Medical Directors, Pharmacy Directors, and various client businesses can find the financial reports that are of greatest interest to them.
Analytics - Clinical
Comprehensive Medication Review (CMR) & Medication Therapy Management (MTM) for Medicare
CMR & MTM address the most significant issues with Medication Therapy: patient therapeutic safety, effectiveness, and outcome.
Physician & Patient Specific Queries™ for Drug Utilization Review (DUR)
Pro Pharma’s analyses provide clarity and help to prioritize high risk problems. Our program analyzes clinical data which utilizes hundreds of clinical edits, patient severity, age/gender, geography, diagnoses, and includes medication compliance.