COMPLEX CLAIMS MANAGEMENT
In 2015, Cubic pioneered the first Member-centric, disease state based Prior Authorization program for complex drug claims, run entirely by independent, Clinical Pharmacists who have no financial interest in the claim. The FACET Prior Authorization Program was developed to ensure medication experts assess every complex case and to ensure the safe and responsible use of specialty drugs.
The FACET Program is a concierge Prior Authorization program that is focused on ensuring Plan Members receive safe, effective and optimized specialty drug therapy for complex disease states where management of claims requires objective, evidence-based decision making.>
The FACET Program highlights:
- An independent, Clinical Pharmacist managing every case end-to-end
- Direct access to the FACET Clinical Pharmacist for the Plan Member and their Physician
- Concierge service for Members where decisions are rendered same day in a majority of cases
- Disease state based (as opposed to drug-based) claims assessments to make sure Members receive the most appropriate, evidence-based medication at the right dose
- Ongoing management of chronic claims to ensure long-term effectiveness of treatment
- Clinical decisions shared with both Members and their Physician with fully transparent, evidence-based rationales
FACET Program Results in 2018
Cubic’s team of FACET Program Clinical Pharmacists have assessed thousands of claims for complex conditions such as Cancer, Rheumatoid Arthritis, Crohn’s Disease, Ulcerative Colitis, Plaque Psoriasis, Psoriatic Arthritis, Multiple Sclerosis, Chronic Migraine Headaches, Chronic Hepatitis C, Asthma, Hypercholesterolemia, Chronic Idiopathic Urticaria, Juvenile Idiopathic Arthritis, Atopic Dermatitis, Diabetic Macular Edema, Cystic Fibrosis, Ankylosing Spondylitis, Cervical Dystonia, Primary Biliary Cholangitis and the list goes on.
In 2018, the FACET Program yielded the following results:
- 96% of claims turned around within one (1) day
- 66% of claims turned around the same day
- Active clinical interventions by the FACET Clinical Pharmacist were required in 44% of FACET submissions in order to ensure Members received the most appropriate therapy for their underlying condition
The FACET Clinical Pharmacy Team needed to actively intervene on almost half of the cases received in 2018 to ensure the most appropriate therapy for the Plan Member and the majority of decisions were turned around within the same day.
The FACET Program is a win-win for the Plan Sponsor and its Members because it ensures optimal use of plan resources from the Plan Sponsor’s perspective, while Members maintain access to the most appropriate, evidence-based therapy.