NexgenRx™   Intervention Suite

Small changes can make a big difference! Gain better control over both costs and patient care with a series of programs that help limit the slippage in your drug benefit plan. The NexgenRx Intervention Suite™ has optional pharmacy programs on monitoring drug usage and efficacy. A specific aspect of prescription drug usage is targeted by each program.

Prior Authorization
Specific drugs are often excluded from a standard formulary plan but may be required to treat certain conditions. If using a less costly medication does not achieve the necessary results, the patient can apply for an exception or Prior Authorization to have the specific drug covered through their plan sponsor.

The NexgenRx™   Prior Authorization program may include medications such as Cox-2 Inhibitors, Oral Erectile Dysfunction drugs, Anti-Obesity drugs, Botox, Biologics issued to treat Rheumatoid Arthritis and Crohn's Disease, Wellbutrin SR for depression and Thyrogen for diagnostic testing.

This program allows access to more expensive drugs to treat specific conditions once the less costly alternative(s) have been tried or the patient's medical condition meets certain criteria. Necessary coverage for the patient is achieved without incurring the higher expense of unnecessary brand name drugs.

Trial Drug Program
The Trial Drug Program prevents the unnecessary wastage of drugs. Frequently, the patient and his/her physician determine a different drug is required due to side effects or ineffectiveness within a few days. If your physician prescribes one of these Trial Drugs under your benefit plan, the pharmacist will inform you that he/she can only dispense a 7 to 10 day supply (depending on the drug) the first time. The pharmacist will only charge his/her regular professional fee plus cost of the amount of medication actually dispensed. However, if NexgenRx   has you on record as having had this medication within the last year, your pharmacist will be able quantity to dispense the full quantity prescribed (up to 100-day supply).

NexgenRx   will adjudicate the transaction and confirm to the pharmacist how much of the submitted amount will be paid by your plan. If the amount is limited, the pharmacist will consult with you and advise you to request the balance of your prescription on a date when the trial amount is depleted. When you request the balance of the prescription, the plan will pay the professional fee and adjudicated ingredient cost of the medication as allowed by your benefit plan. You will have to pay your co-pay/co-insurance portion based on the allowable ingredient cost of the balance of the medication. There are two conditions under which the pharmacist can override this program:

1) that you have received the same medication previously with the last 12 months and

2) the physician has provided you with a sample of the medication previously.

The NexgenRx   Trial Program includes regularly prescribed brand name drugs with a relatively high unit cost where the cost justifies paying for a potential second dispensing fee within a 34-day period. In general, the program would not include:

  • generic drugs
  • any drug whose 34-day supply cost is less that the average dispensing fee
  • drugs that usually have to be taken for at least 4 weeks before noticeable improvement
  • drugs whose packaging does not easily lend itself to a 7-day supply
  • narcotic and controlled drugs
  • drugs taken on an as-needed basis

The most common examples of drugs included in the program are those that can cause GI upset, drowsiness and muscle weakness. Statins (Lipitor, Crestor) and fibrates (Lipidil) widely prescribed for lowering cholesterol fall into this category. 

Dynamic Maintenance Program
Dispensing fee costs can be reduced by allowing a 100-day medication quantity to be dispensed. In general, the patient and physician know if acute drugs become maintenance drugs after two consecutive monthly prescriptions. At the third monthly prescription, plan sponsors can have the system request a 100-day supply be dispensed, thereby saving the cost of two additional dispensing fees.

Pharmacy Primary Care Services
The pharmacist is the most important link in cost containment and has a unique tie to the patient and input at the delivery stage of their healthcare. Three programs have been developed with pharmacy that allow pharmacists to deepen their client relationship while benefiting both the patient and the plan sponsor with improved health outcomes.

Disease Management Programs
Many of a pharmacist's regular clients deal with ongoing health issues. We offer information through pharmacy on some of the most common health conditions including Diabetes, Cardiovascular ailments, Hormone Replacement Therapy (HRT) and Smoking Cessation to help clients manage their health on a day-to-day basis.

Comprehensive Medication Profile Reviews and Compliance Counseling
Frequently the local pharmacist has the best idea of exactly what medications a regular client is taking. The pharmacist may be the only professional who knows both the patient's medication usage and resulting pharmaceutical interactions across several physicians for different conditions. NexgenRx   has arranged for pharmacists to offer patients a comprehensive medication profile review and/or compliance counseling at the time a drug is dispensed. Plan sponsors can offer this benefit to employees at a shared cost and, along with the employee, benefit from improved health outcomes.

The NexgenRx   Intervention Suite™ is available as a package or by individual program. Please call your NexgenRx   representative for more information.