By the
2008 AASCIF Claims/Rehabilitation Standing Committee
 “The
First Fill Myth,” an article by Nick Page recently published
in PMSI Perspective, challenges the value of the current effort
by the insurance industry to find a solution to first fill. The
article goes on to analyze the cost savings potential from first
fill: 5 percent of total savings potential, compared to a potential
savings from chronic injuries reported to be 65 percent of total
savings potential.
Although Page makes some good points in this article, the value
in finding an effective first fill solution is about more than
cost savings. As state funds, we should be particularly interested
in solving problems within our workers’ compensation systems.
First fill is an attempt to solve one of those problems.
Without a first fill solution, injured workers and pharmacies
are caught in a “no man’s land.” An injured worker
may present his initial prescription to a local retail pharmacy
before the first notice of injury has even made its way to the
insurer. The worker has no claim number, adjuster name, or pharmacy
card, leaving the pharmacist to make the decision whether to charge
the worker out-of-pocket or fill the prescription and hope it will
be reimbursed by the insurer when (if) the claim is accepted. This
is not a good situation for the pharmacy.
Most likely, the injured worker will be expected to pay for the
prescription up front. Many workers may not want, or may not be
able, to pay out-of-pocket for their medication. This can potentially
leave the worker without needed care.
The insurer may not know about the claim to verify coverage, much
less have compensability resolved. This translates as a missed
opportunity to benefit from negotiated pharmacy discounts, and,
more importantly, we miss the opportunity to encourage the use
of cost-effective, evidence-based medications, those clinically
proven as effective in addressing the workers’ injury.
Many insurers, primarily through their pharmacy benefit managers
(PBMs), are offering solutions. More and more PBMs are including
a first fill feature in their offerings. Typically this involves
a card or letter issued by the policyholder at time of injury or
downloaded from the insurer’s website. The card guarantees
payment for a single prescription and usually expires within 24
hours of issuance. The PBM accepts responsibility for the first
fill cost even if the claim is ultimately denied. It seems clear
that the negotiated pharmacy discount rate must account for this
assumed cost on the part of the PBM.
Some states have taken legislative action. In 2007 Washington
State passed a bill that requires the State Bureau of Labor and
Industries, Washington’s monopolistic state fund, to guarantee
retail pharmacies payment for initial prescription drugs. The Washington
State Pharmacy Legislative and Regulatory Affairs Council advocated
for the legislation.
SAFI Corporation, Oregon’s state-chartered workers’ compensation
carrier, has taken another approach. Although Oregon law does not
require carriers to pay for first fill coverage, SAIF has elected
to provide a limited number of cost-effective medication benefits
for new claims in order to help injured workers get through those
first days after an injury and before the claim is accepted. The
first fill benefit is only available through SAIF’s pharmacy
benefit administrator, the Oregon Prescription Drug Program (OPDP),
ensuring that medications prescribed prior to claim acceptance
are filled at the most competitive cost. Offering a limited formulary
of evidence-based medications may result in workers staying with
these proven medications even after claim acceptance.
SAIF issues a first fill letter to injured workers upon receipt
of the notice of injury, and the worker presents the letter to
any OPDP panel pharmacy. The SAIF first fill benefit is available
until the claim is accepted or denied. If the claim is ultimately
denied, the cost is absorbed by SAIF.
Many other solutions may yet be developed to resolve the “no
man’s land” between the time of injury and claim acceptance.
It is our charge as state fund industry leaders to continue to
improve the first fill pharmacy delivery and payment process. If
we do not, someone else no doubt will; but at what cost?
|
