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*This email is intended for producers in Delaware, Pennsylvania, and West Virginia HIGHMARK'S NEW SPECIALTY DRUG PROGRAM, FREE MARKET HEALTH, EFFECTIVE AUGUST 1, 2021 Highmark has engaged with and invested in Free Market Health (FMH) to leverage their value-based marketplace platform. With the FMH platform, all specialty pharmacy and Home Infusion providers can compete to serve our members’ needs, considering both drug cost and how to best serve the patient. The FMH platform will:
- Streamline prior authorizations and get patients started on therapy sooner.
- Be easily accessed as part of our prior authorization process through Navinet.
- Help find the best fit specialty drug provider for each individual patient based on cost and quality.
The FMH platform is split into multiple components:
- Real Time Authorization (RTA): The RTA (Real Time Auth) component of the project, which is the intake gateway the prescribers will use to initiate the FMH process, will improve speed to therapy for the members by automating and shortening the time it takes for drug authorizations and referrals, reducing the time from days/weeks to hours.
- The Marketplace: Instead of having an exclusivity arrangement with a particular pharmacy, the FMH platform will allow for dynamic pricing on specialty pharmacy drugs – on both the medical and pharmacy benefit – through the use of a marketplace where contracted specialty pharmacies will be able to bid competitively on referrals. The bidding process will provide real-time best pricing on high cost specialty medications.
- Value Based Reimbursement: Creates real-time patient care accountabilities for providers. Members will be stratified during the intake process into a high or low touch model of care which the providers will be able to take into consideration during the bidding process. (Specialty pharmacies tend to have expertise within specific drug/disease states). The goal is to have alignment between the drug, the member, and the pharmacy. Providers will have the opportunity to earn a value – based reimbursement based on certain metrics for each drug/disease state.
By partnering with FMH, we hope to bring true innovation and positive change to the way specialty pharmacy drugs are supplied, realigning resources, risk, and accountabilities.
This program will be effective for members enrolled in one of the following Commercial Fully-Insured plans:
- Large group
- Comprehensive Products
- EPO/PPO/HMO/IPA
- HDHP
- Administrative Services Only (ASO)
The following plans will not be a part of the initial rollout of FMH, with anticipated availability listed next to each plan:
- CHIP – Medical and Pharmacy - 2022
- Medicare – Medical benefit – 2022
- Medicare – Pharmacy benefit – 2023
- ACA Individual and Small Group – Medical and Pharmacy – 2023
How the Program Works
Free Market Health begins with one of the central functions of the platform, Real Time Authorization (RTA). This web-based tool is utilized by prescribers to start a patient on a specialty drug. Covered members are identified in real-time and the specialty drug authorization yields a managed, authorized referral.
After authorization, the FMH referral router evaluates attributes (e.g. group benefit rules, exclusive supplier, etc.) of each referral to determine if that referral has a pre-defined home. If it does, FMH routes it directly to the intended pharmacy within seconds. Referral routing enables execution of custom Highmark strategies, like health system client enablement.
Prior to entering the Marketplace, each referral passes through a proprietary stratification algorithm that systematically evaluates the patient, drug, and disease specific attributes. The goal of stratification is to determine what type of care model is best suited for each patient.
Referrals that are stratified as high-touch are dynamically assigned value-based performance requirements, which are patient-specific care accountabilities for the specialty provider to execute on. This process enables optimized high touch member care by a specialty pharmacy that’s incentivized and accountable.
High and low touch authorized referrals enter the FMH Marketplace where contracted specialty drug providers have access and compete in real-time for the opportunity to serve a member. Specialty drug providers can evaluate and compete for the referrals that are best suited to their patient care models based on care accountabilities and service incentives.
Effective August 1, 2021, certain drugs that are processed under the medical benefit will go through the RTA platform and be sent to the marketplace for bidding.
The drug categories for the initial roll out include Chronic Inflammatory Disease (CID) drugs and Hepatitis C drugs.
The drugs in scope for the Free Market Health program are subject to change and will be reviewed by the Highmark Pharmacy team for updates on a regular basis as we continue to grow the program for both the medical and pharmacy benefits.What does this mean for fully insured clients? The Free Market Health program will be rolled out to all active groups as of the effective date of 8/1/2021.What does this mean for ASO clients?The Free Market Health program will be available to ASO clients as a product offering in the near future.The ValueThe Free Market Health platform delivers both economic value and clinical value by delivering the best drug price in a value-based framework. The platform gets the patients to the right care models at the right price. This platform will eliminate the one size fits all approach, because excludes the need to contract with one specialty pharmacy.Value to the member
- For the member, the platform applies optimized drug/disease care management, eliminating that one size fits all specialty pharmacy contracting approach. This platform will also increase the member’s speed to therapy.
Value to the client
- For the client, the best rates are achieved in real time on high cost specialty drugs through the marketplace. This creates a streamlined and optimized experience for their employees on a specialty drug. There is also the potential for long term ROI based on the member’s care management outcomes.
Questions? If you have questions, please contact your Highmark Client Manager or Sales Executive.
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Highmark Inc. is an independent licensee of the Blue Cross Blue Shield Association. Insurance or benefit administration may be provided by or through Highmark Inc. or one of its affiliated Blue companies. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies serve Blue Cross Blue Shield members in the 29 counties of western Pennsylvania, 13 counties in northeast Pennsylvania, the state of West Virginia plus Washington County, Ohio, and the entire state of Delaware. |
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