Prescription plan data model

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Prescription plan data model

Description Understanding the prescription drug plan data model
Version as of 8.6
Application Pega Foundation for Healthcare
Capability/Industry Area Healthcare and Life Sciences



Overview[edit]

Just as medical, vision and dental health insurance plans are offered in the healthcare industry, prescription drug plans (or sometimes called pharmacy plans) are benefit plans that cover members’ drug expenditures. The spiralling costs of prescription drugs have forced payers to carve out these benefits into separate plans. The key advantages to each party in the healthcare ecosystem include:

For Payers: Outsourcing the administration of drug benefits eases operational burden and reduced loss in revenue through rate negotiation with Pharmacy Benefit Managers (PBMs) particularly for specialty drug prices

For Members: Lowered out-of-pocket costs, especially at preferred pharmacies, and a wider range of access to prescription benefits

For Pharmacy Benefit Managers: Increased membership base allows greater leverage for PBMs when negotiating contracts with drug wholesalers and manufacturers, and higher profits allow investments into modern business systems

Prescription plans are made available by payers for various lines of business, such as Medicare, Medicaid, Commercial (Group) and Individual plans.

Prescription drug plan (PDP) elements[edit]

Drug lists

  • Covered drugs: Also known as formulary drugs. These are covered by the plan with applicable cost shares based on the tiers or categories into which the drug falls
  • Excluded drugs: Also known as non-formulary drugs. These are not covered by the plan unless an exception request is received and approved by the payer
  • Alternative drugs: These are suggested alternative drugs (from the formulary) to those that are not covered by the plan

Requirements and limits

  • Step therapy: Members are asked to try lower-tier drugs first when high-cost drugs are requested
  • Quantity Limits: Payers set limits on quantity of drugs that can be filled as part of their utilization management programs e.g., Opioid drugs
  • Prior Authorizations: Certain drugs especially specialty drugs, require prior approvals from payer before being filled
  • Dispense as Written: Allows providers to specify to pharmacies to skip generic substitution for the drugs they have prescribed
  • Days Supply: Quantity of drugs requested to be filled based on prescribed dosage
  • Refills: When members request for refilling their drugs, rrestrictions are applied by payers to prevent drug-abuse i.e., of controlled substances

Pharmacy networks

  • Preferred: Pharmacies considered to be ‘in-network’ and that offer lower cost shares
  • Non-preferred: Pharmacies considered to be ‘out of-network’ with limited coverage, higher cost shares (or) no coverage

Delivery channels

  • Retail: Physical stores like community, hospital or grocery store pharmacies
  • Mail: Paper forms or dial-in methods for filling prescriptions
  • Online: Omni-channel presence where members can order online via app or website

Use cases[edit]

The prescription drug plan data model has several applications ranging across functions and departments of a healthcare payer enterprise.

Customer service: A member’s enquiry regarding drug benefits and accompanying recommendations

Care management: Prior authorizations for drug benefits can be processed by medical review teams

Product development: Benefit teams can configure prescription drug plans and formularies

Sales and marketing: Quoting and rating of prescription drug plans for sales agents

Claims: Adjudicators can review and process a member’s claim on drug expenses

PDP in Pega Foundation for Healthcare[edit]

Pega Foundation for Healthcare (PFHC) 8.7 includes all the essential classes and related attributes to create and manage prescription drug benefits and formularies. This data model references Centers for Medicare & Medicaid Services (CMS) format for Medicare prescription drug plans, with efforts in future towards expanding this model to accommodate other lines of business at a payer.



Following are the key data classes that can be extended based on business implementation needs:

  • PegaHC-Data-
  • PegaHC-Data-Plan
  • PegaHC-Data-PrescriptionDrug
  • PegaHC-Data-BeneficiaryCost
  • PegaHC-Data-BenefitTiers
  • PegaHC-Data-PharmacyNetwork

User can access Foundation’s demo portal by logging into UHealth Demo Application to upload the prescription drug plan’s data:

  • Launch the demo portal
  • Go to ‘Administration’ tab
  • Click on ‘Upload prescription drug plan data’ sub tab
  • Select the class against which data is to be uploaded
  • Choose the file i.e., template which contains the data
  • Click on ‘Upload’ button



Review the plan in terms of plan’s key attributes, coverage levels, benefits, and beneficiary (member) costs and formulary document in PDF format: