PLANBUILDER

     One important component of the TeleClaim system is a software package called "PlanBuilder". PlanBuilder is the primary tool used for the construction of a Benefit Plan, with its own formulary, by a simple, easy to use fill in the blanks procedure.

     A limitless number of plans may be entered and stored in the TeleClaim system. These will be created by the administrator and staff for immediate or delayed activation in the Adjudication process of the TeleClaim system. The plans are stored in a data file and any plan may be called into the adjudication process when identified as the plan corresponding to an individual, group, etc.

     Fine tuning and rifle targeting of specific Benefit Plans can be accomplished with minimal effort by creating many more groupings than you may have today. A plan may even be reduced down to an individual member as mentioned earlier. Instead of having one-size-fits-all Benefit Plans, the administrator can customize Benefit Plans to the population mix of sex, age, family size, length of membership, location, account et al and, thereby come closer to optimizing cost-effectiveness.

     Plan Builder also accommodates Mail Order and Direct Member Reimbursement plans in addition to the ordinary POS-based Drug Benefit Plan.

     In other system you can have the option of selecting a benefit plan from a library of choices or those that require several days, weeks, or month to customize a special plan (i.e. big service bureaus). TeleClaim on the other hand, offers significant advantages to those who need more flexibility and speed of implementation by providing same day updates to a plan formulary using Plan Builder. This "hands-on-the-wheel" control appeals to many administrators who are under pressure to respond to management’s demands for including new members with a different plan or for changes to an inefficient plan already in operation.

     Today, rapid and regular benefit plan and formulary changes are becoming more commonplace. Rebate programs are themselves changing rapidly due to the shift in the influence of the Drug companies who now own the majority of service bureau drug processors. Opportunity for more and greater rebate amounts has created the need for quick response to formulary changes that were almost unheard of just a short time ago. Thus, the need and attraction of PlanBuilder to the Administrator.

     Initially, the administrator will create the original plan structures. As any new plans are recognized as very similar to earlier created plans, a copy feature is used to replicate an earlier plan, given new identification, and then only the differences need be entered. This saves a great deal of entry time and possibly minimizes any potential erroneous entry.

     Some of the parameter fields are optional or may have a default feature. Mandatory parameter fields require a response and the program will indicate those that have been skipped. In such cases, the end-of-screen control forces a return to the field(s) that need attention before allowing a continuation to the next page. The book assumes all drugs, Rx and OTC, are covered unless the user employs available features and operations of the book to exclude or restrict their dispensability.

     Now, let us briefly survey each page of the Book to understand its capabilities.

Page 1. Restricting By 3rd Party Codes, Creates formulary by general type groupings. These groupings are marked for exclusion and/or designated for Prior Authorization.

Page 2. Restricting Over-The-Counter Drugs. Similar in restricting to Page 1 method.

Page 3. Ingredient Cost Formulations. Broad flexibility in constructing the method of calculation for the plan.

Page 4. "Dispense As Written". DAW can restrict and/or influence the drug dispensed method of reimbursement, provider actions taken, etc. Ten categories DAW are used.

Page 5. Dispensing Fee Formulations. Starts with four choices of methods. Other variables can be introduced for further variations to suit, even by Preferred Provider.

Page 6. Copay Calculations. Complete range of popular and common methods provided to enable recipient incentives toward requesting certain preferred drugs.

Page 7. Claims Administrative Expense. Used by service bureaus and PBM for billing clients or for withholding fees for distribution to the provider.

Page 8. Special Dispensing Limitations. This enables maximum days-supply, quantity, age, beneficiary status, maintenance drugs, et al, as basis for restricting use.

Page 9. Maximum Quantity Restrictions. Absent any other overrides, the user can globally address quantity limitations for the plan with a number of choices.

Page 10. Special System Edits and Other Limitations. Collateral restrictions may be imposed based on status of Prescriber, Provider, and variations in eligibility validation.

Page 11. Deductibles and Maximum Benefits. A multitude of variations to this general area of cost containment are provided covering all aspects related to maximums.

Page 12. More Deductibles and Maximum Benefits. A continuation of page 11.

     Simply stated, the Book is first used to develop standards of restrictions and allowances for the plan being customized. The Appendices then play the role of providing selective and rifle targeted variations to the basic structure (i.e. if an entire class of drugs, which may have several dozen drugs in its class, is excluded by page 1 of the book, a user may wished to include one drug in that class without entering dozens of individual exclusions by NDC number).

     Trade are 15 different appendices to complement the Book with these overriding exceptions. Each is attached to the designated benefit plan define in the Book pages. Every plan my have all fifteen individual appendices and each may be exclusive to the plan.

• Override of Class Exclusions by Specific Drugs
• Mandatory PAR for Drugs Ordinarily Exempted by Class
• Designating a Brand Premium by Specific Class
• Drugs Forced To Be Treated as Maintenance Drugs
• Mandatory Generic Copay Pricing By Drugs
• Zero Copay Designation by Drugs
• Copay Flat-Amount Override List Of Drugs
• Copay Percentage of Cost Override List of Drugs
• Multiple Copay For Extended Days-Supply List of Drugs
• MAC Price List By Drugs
• Mandatory Drug Exclusion List
• Drug Specific Maximum Days/Quantity List
• Prescriber Specialty Restriction Drug(s) List
• Lifetime and Annual Maximum Benefit Designation
• NDC Lockouts List of Drugs

     This being the case, it follows that closer control and scrutiny is sought by the managers of drug therapy programs. They wish to encourage certain and appropriate utilization with the most cost effective drugs.

     PlanBuilder is the most advanced tool to devise benefit plan. It fits individuals and groups with as many and varied techniques of control that one could wish to employ

The highlight of PlanBuilder are:

• INDIVIDUAL PLAN FORMULARY CUSTOMIZATION SIMPLY PERFORMED
• INCLUSION AND EXCLUSION OF DRUGS BY 3^RD PARTY CLASSIFICATION
• INCLUSION AND EXCLUSION OF DRUGS BY NDC OR GPI/GCN
• BROAD EXCLUSION WITH RIFLE TARGETED EXCEPTIONS
• MULTIPLE METHODS OF CALCULATIONS FOR COPAY, COST, FEE, ETC.
• DIVERSIFIED METHODS OF HANDLING DEDUCTIBLES AND MAXIMUM BENEFITS
• MAC PRICING FLEXIBILITY
• FORMULARY ENFORCEMENT WITH HARD AND SOFT CONTROLS