Prescriptions are a significant cost driver for health plans and the ability to easily identify high cost PCPs and high cost members supports the strategies developed to respond to these costs.  

 

 

Target Audience for this Report 

Chief Medical Officer, Finance Department and CFO, Leadership Team, Medical management/Care Management Department, Pharmacy & Therapeutics Committee, Physician Relations, and Utilization Management.

 

Business Processes Impacted by this Report

The P&T Committee, CMO, Medical Management and PBM will use this report to track, trend, and evaluate prescriber patterns.

 

The data assists the health plan in evaluating the effectiveness of prior authorization or quantity limits placed on medications.

 

High cost pharmacy utilization data supports health plan forecasting of costs, rates, and premiums.

 

High cost pharmacy data informs health plan of potential care management needs.

 

Detail and Definitions

This entire visualization is based detailed reporting period, including the header information; “Total Scripts”, “Total Paid”, and “Paid/Script”.  Note that the header information is active and will change when selections are made/filters are applied.

Highest Cost PCP

  • Provider Name
  • Patients
  • Script Count
  • Total Paid

 

Highest Cost Rx Members

  • Member Number
  • Member Name
  • Total Paid
  • Rx Claims

 

Drug Classes by PCP

  • Drug Class
  • Scripts
  • Patients
  • Total Paid
  • Paid/Patient

 

Drugs Prescribed by PCP

  • Drug
  • Scripts
  • Patients
  • Total Paid
  • Paid/Patient

 

Note that filtering order in the visualization is:

  1. Highest Cost PCP (not required)
  2. Highest Cost Rx Members (not required)
  3. Drug Classes Prescribed by PCP (not required)

 

This report brings added value in that the tables function independently, or via filtered sets.

 

The PIE Chart set “Generic vs Brand % by PCP” shows the percentage of Brand vs. Generic for both “Total Paid”: and “Scripts”.  Note that these pie charts are only influenced by the selection of a PCP.

 

The drug classes and codes are based on the NDC table (linked from the NDC code on the pharmacy claims).