EHIM provides a customized pharmacy benefits to the workers' compensation industry. Our long standing client relationships include insurance carriers, third party administrators (TPAs), and self-insured employers.
Our proprietary claims system uses the newest technology and allows EHIM to create custom, injury specific formularies to manage comp claims from the first fill through the duration of the claim. Our clinical programs and clinical team support the case managers and adjusters to maximize channel utilization, dose optimization, and trend management while our pharmacy network of over 64,000 participating pharmacies
support network penetration and retail or mail order opportunities.
EHIM remains dedicated to client and member satisfaction by delivering best in class service, savings, and benefits through our 24/7/365 Pharmacy Call Center, detailed reporting, and ease in overall program administration.
Trends in Workers Compensation
The workers compensation industry is ever-changing, from statute revisions to new approaches for managing disability and medical costs. The prescription drug landscape for workers’ compensation is just as dynamic.
During 2009 and 2010, major market forces were the revision of pharmacy fee schedules by several states, and updating of reporting requirements by other states. As these types of market forces emerge, pharmacy cost trends are impacted, creating a new set of challenges for workers’ compensation payers. This results in increased attention to the cost and use of prescription drugs.
Utilization management is critical for controlling drug trend. At EHIM, workers compensation plan managers have the ability to authorize or deny non-formulary medications. EHIM has created programs to help our clients review medication use and handle claims proactively. Our clinical pharmacy programs facilitate improved quality of care for injured workers, enhance therapeutic outcomes, and reduce prescription-drug expenditures.
In addition to other clinical programs — like formulary edits, Concurrent Drug Utilization Review (DUR), and Retrospective DUR — EHIM provides an additional layer of edits. Our Clinical Management team monitors possible drug-therapy problems and helps clients identify potentially inappropriate patterns of use. Examples of possible misuse are unusual narcotic usage, duplicate therapy, excessive therapy duration, overlapping prescribers, and questionable relevance to injury.
The use of generic medications is a primary factor in controlling drug cost. EHIM has a long history of leading the Pharmacy Benefit Management industry in driving the use of generics. In 2009, our workers compensation clients achieved an average generic dispense rate (GDR) of 74%, which measures the percentage of total prescriptions dispensed as generic medications. By adopting clinical programs that address both single-source and multi-source brand medications — including the Physician Outreach Program and Step Therapy — our clients have the ability to reach GDRs in excess of our book-of-business average.
Ensuring that prescription drugs are dispensed through the appropriate delivery channel is another key element to managing costs. By increasing the use of network pharmacies and Mail Order while reducing the use of third-party billers, EHIM clients can successfully reduce their overall drug spend, while ensuring an efficient and stress-free experience for the injured worker.