Comprehensive program ensures efficiency and ease of use
PMSI’s Retail Pharmacy program is a component of the PharmaComplete™ solution that addresses the complete retail pharmacy lifecycle, from first fill to final bill. The program offers convenience for injured workers as well as claims professionals by providing fast, accurate prescription dispensing with no out-of-pocket expense on approved medications.
Retail Network (Tmesys)
The density and success of our network, known as Tmesys—with nearly 65,000 participating retail pharmacies nationwide—ensures injured workers have access to quality pharmacy care from trusted and familiar pharmacies close to home or work.
Instantly at the point of sale, prescription claims are analyzed before medications are dispensed. In seconds, each transaction is compared against a series of over 100 prospective drug utilization review (DUR) edits, automatic generic conversion mandates, step therapy rules, and a workers’ compensation-specific formulary. This helps safeguard injured workers by ensuring the most appropriate therapy for the injury is being utilized, without relying on claims professional intervention.
To gain maximum network penetration, our all-points strategy centers on managing the channel, as well as the therapy, to ensure that eligible prescription claims are processed online where clients benefit from the full measure of PharmaComplete’s checks and balances. The focus is to ensure ease of use and quality care for injured workers and in-network savings for clients. These comprehensive, yet customizable programs drive appropriate utilization and compliance with program parameters to capture prescriptions at the earliest opportunity and keep transactions in-network for maximum clinical oversight, reporting and savings.
- PMSI has formed industry-leading partnerships with two of the largest nationwide pharmacy chains, which account for nearly 40% of all transactions. These partnerships use Automated Re-indexing to ensure nearly all transactions belonging to PMSI clients are adjudicated as in-network transactions. This program consistently demonstrates results of 99% network penetration with these pharmacy partners. The number of out-of-network bills are reduced and the ability to apply clinical controls is increased—ultimately driving savings for clients.
- Starting with the first prescription fill after injury, PMSI’s First Fill program helps to adjudicate prescriptions for newly injured workers—guaranteeing payment on up to a 10-day supply of approved medications at the contracted rate and at no risk to the client should the claim later be denied or inadvertently never filed. This enables injured workers to begin drug therapy regimens as quickly as possible while their claim is in the initial intake and processing stage.
- After notice of injury is received, PMSI sends a Pharmacy Card to the injured worker with information on how to use the program and easily locate a convenient pharmacy.
- Injured workers are encouraged to download the VitalPoint® MyWorkComp™ mobile app to find a nearby pharmacy, access their pharmacy card, or manage their medication record on the go.
- With the Samaritan Dose program, should a prescription require authorization from a claims professional that cannot be reached (due to weekends or non-business hours), PMSI will dispense up to a 5-day fill of the medication, ensuring that the injured worker has the prescriptions needed while waiting for approval on the complete fill of medication.