Public Sector Market Drivers
Public sector organizations that provide prescription drug benefits are faced with a formidable challenge: managing rising drug costs with diminished budgetary resources.
At the federal level, implementation of the Medicare Part D drug benefit in 2006 increased Medicare’s share of total national prescription drug spending from 2% in 2005 to 21% in 2008*. Meanwhile, state Medicaid programs are looking for organizations to provide innovative strategic initiatives that can manage escalating costs without diminishing the level of services offered.
Today, public sector organizations are searching for solutions that deliver both cost-containment initiatives and enhanced patient care. Medicaid and other government programs seek PBMs and PBM technology companies that understand the unique public sector environment and have the flexible platform required to accommodate their special needs. These organizations need a competitive fee-for-service model with a robust claims processing engine supported by strong clinical and benefit-design support and consultation.
We deliver transparency, flexibility and choice
SXC’s applications and services enable customers to: apply their benefit design to their own unique standards, with greater automation and flexibility; decrease administrative costs without compromising service quality; and enhance understanding of public entities’ needs for pharmacy spend management, requirements, and regulations.
SXC’s products and services for the public sector include:
Point-of-Sale Claims Processing — Our robust and flexible on-line transaction processing systems provide real-time adjudication of third party prescription drug claims at the point of service. We offer automated features which provide ease of use and flexibility for clients. Our systems help clients more effectively manage: the payment of claims, benefit designs (including plan setup), pricing, recipient eligibility, product coverage, provider coverage, and DUR management. Our systems are designed using rules-based, table-driven architectures which provide our clients with state-of-the-art flexibility and rich features to meet their needs across many markets, including Fee-For-Service Medicaid, Managed Medicaid, Medicare Part D, health plans, third party administrators, PBMs, and governments.
Preferred Drug List Development and Administration — We can fully support our clients’ existing preferred drug lists or we can collaborate to create best-in-class models supported by formulary predictive modeling and impact analysis. Pharmacist, physician, and member-focused intervention protocols provide quality controls to drive generics, preferred drug products and appropriate use. As an independent (non-manufacturer owned) provider, we have no hidden agendas relative to promoting products to our clients. We can administer formularies based on specific plan designs, or we can provide clients with the tools to maintain their own custom formularies online.
Drug Rebate Administration — SXC implements a software and business process solution that is based on its current rebate administration application, RxMAX®. This flexible, table-driven system processes hundreds of millions of claims annually for our clients. RxMAX utilizes both CMS and NCPDP rebate standards as its foundation, allowing it to support the entire rebate process for OBRA 1990, Medicaid Supplemental, and CHIP (Federal match and State-only) rebate programs.
Prior Authorization (PA) — To help relieve providers of the administrative burden often associated with PA procedures, SXC has developed the RxAUTHTM point-of-sale PA process. RxAUTH is a proprietary automated PA program that provides the flexibility and customization that can match our client’s specific needs. This prior authorization program allows for a traditional prior authorization approach, and also enables robust automated prior authorization functionality.
Drug Utilization Review — Pre-dispensing DUR edit checks are performed on an online, real-time basis between mail and retail pharmacies. All prescriptions are checked for participant eligibility and plan design features and are then compared against previous histories of prescriptions filled by the same pharmacy, other participating retail network pharmacies, or the mail service pharmacy.
Reporting and Information Analysis Solutions — We provide two main levels of reporting: our standard reporting package (which includes a large menu of unique reports), and our online analytical decision support tool, RxTRACK®, designed to furnish all of the functionality that any of our clients may need in the area of reporting.
SXC currently provides solutions to public sector groups in both the U.S. and Canada, including: federal, state Medicaid, and provincial drug programs; Department of Defense Veteran’s Administration, and state employee programs; and Medicare Part D. SXC’s fee-for-service model delivers the flexibility and transparency of operations that are required by public sector organizations, and helps them to better control their drug program costs.
In the established public sector model, each public sector client operates unique programs, and requires a partner that can interface with other vendors and seamlessly support new requirements as needed. Our ability to combine our tools, technology, and expertise into a customized package makes us exceptionally well equipped to serve the entire range of public sector entities.
* CMS, Office of the Actuary, National Health Statistics Group, January 2009.