Steps Employers Can and Should Take with Suppliers
The impact of hemophilia on your company’s spend and/or hospital and ER use can be verified with ICD-9 or ICD-10 codes, hemophilia drug J-codes and/or NDC numbers. Work with your vendor partners, e.g. PBMs, health plans, specialty pharmacies, to collect the information below.
Step 1: Know the number of individuals with hemophilia currently being covered as primary and secondary by your plan.
Step 2: Determine the specialty drug spend related to hemophilia; clarify whether the spend is captured under the medical plan, pharmacy plan or both.
Step 3: Ask your health plan/claims administrator to pull ER and hospital claims data with hemophilia as the primary diagnosis code.
Step 4: Evaluate your current benefit plan design to determine if:
Step 5: Hold your vendors accountable.
Conduct a retrospective review to ensure that your vendor partners are doing what they say they are doing and require quarterly reports with specific requirements, including:
- Assay management performance reviews
- Identify target dose as written compared to actual dispensed dose
- Identify current contracted allowable +/- over target
- Dose management performance reviews
- Ordered versus shipped - oversight/reporting to confirm that dispensations match shipments
- Patient bleed logs (collected and reviewed) to determine medication adherence and inventory on hand at the patient’s home
- Whether auto-shipping has been disabled
The National Hemophilia Foundation offers support to employers at no cost. A consultant/broker may also be able to conduct a retrospective review. Be sure to ask if any fees will be charged for this before starting.
Step 6: Check stop-loss policy (if utilized) and claims to confirm:
- Whether medical and/or prescription drug claims are covered in combination or as separate stop-loss thresholds
- Amount of coverage and qualifying thresholds for stop-loss coverage to begin
- Types of claims covered and timeframe for coverage
- Number of treatment episodes reaching payment thresholds over three individual but consecutive plan years
- Total amount of coverage provided for each