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Pharmacy Benefit Management engine
Innovative solution for insurance companies and TPAs to fight excessive claims and admin expenses
accuracy of medical decisions
%
99
99
automation level
of pharmacy pre-auth
and claims
90
90
%
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We will contact you within 24 hours
Wrong prescriptions can harm the patient
Strict regulations on pharmacy approvals time
Regulatory & Clinical Guidelines compliance
Reduce excessive claims
& administrative expenses
& administrative expenses
Clinically safe and patient-clear decisions
Automated drug checks & Cost savings
Problem
Solution
excessive prescriptions
%
20
20
Regulation compliance
Works with FDA / SFDA drug codes (and NPHIES denial codes in KSA). Compatible with EBP technical requirements
AI-powered
Solution can work with free text description of drugs. Important for the providers whose price lists are not codified
Large Medical Database
Covers 10K ingredients & 50K brand names, 50M interactions between ingredients and 25M drug-diagnosis combinations
References
to Clinical Guidelines
All PBM’s decisions coming with understandable description and contains reference to UAE MOHAP /KSA / US / EU clinical sources or FDA / SFDA
Flexible customization
Ability to tune medical (drug-diagnosis, drug-drug, etc.) and technical (drug-members class) criteria
System features
Pharmacy claim
When a pharmacy submits a claim, MainsLab PBM checks if it matches the prior approval. If no approval is needed, medical checks are performed to determine if the claim should be paid
Prior approval for drugs is a recommen-ded practice, however, if it’s absent, regular medical checks for dosage, course size etc will be applied by PBM
Pharmacy dispensation
Patient with his approved prescription now goes to the pharmacy. PBM checks that the drug dispensed is the drug that was prescribed
Now the medical checks are not needed, and the pharmacy will get compensation if they fulfil the prescription correctly
Prescription Approval
Patient goes to the hospital for a prescription. Medical checks of the prescribed drug are done by MainsLab PBM
The approved prescription includes drug's scientific name, dosage, quantity and duration. The patient can now go to the pharmacy or receive the medication at the clinic
Timeframes for full implementation of PBM in your company
PBM Process
3 weeks
to start using the solution
4 weeks
to receive and analyze the first results
Technical & Regulatory
High dosage warnings (dosage is excessive/dangerous for the patient)
Source KSA: SFDA drug instructions base
Source UAE: FDA drug instructions base
Source UAE: FDA drug instructions base
Drug Coverage: Exclusions of drugs / conditions based on members TOB
Source: Payer's TOB
Tiering (classification of brand/generic with check of co-payments)
Source: Business logic / Payer's TOB
Devices/consumables/milk checks based on Payers ToB
Source: Business logic / Payer's TOB
Utilization rules: one-time quantity / annual limits / monthly limits
Source: Business logic / Payer's TOB
Authorized vs dispensed medication (for products requiring pre-auth)
Source: Business logic
SFDA formulary check
Source KSA: SFDA drug instructions base
Source UAE: Local governmental lists of approved medications (e.g., mohap.gov.ae/en/w/registered-medications-list)
Source UAE: Local governmental lists of approved medications (e.g., mohap.gov.ae/en/w/registered-medications-list)
Medical
Drug-to-Age check
Source KSA: SFDA drug instructions base
Source UAE: FDA drug instructions base, https://dps.fda.gov/medguide
Source UAE: FDA drug instructions base, https://dps.fda.gov/medguide
Diagnosis-to-Gender and drug-to-gender check
Source: Medical logic
Drug-to-Drug interaction
(including form of drug)
(including form of drug)
Source KSA: SFDA drug instructions, https://drugcentral.org,
https://www.drugs.com/
Source UAE: FDA drug instructions, https://dps.fda.gov/medguide,
https://www.drugs.com
https://www.drugs.com/
Source UAE: FDA drug instructions, https://dps.fda.gov/medguide,
https://www.drugs.com
Drug-to-Diagnosis contraindication
Source KSA: SFDA drug instructions, https://drugcentral.org,
https://www.drugs.com/
Source UAE: FDA drug instructions, https://dps.fda.gov/medguide, https://www.drugs.com
https://www.drugs.com/
Source UAE: FDA drug instructions, https://dps.fda.gov/medguide, https://www.drugs.com
Course size limit
Source: Medical logic
Drug vs Clinical guidelines
(medical necessity)
(medical necessity)
Source KSA: KSA clinical guidelines (CHI, saudifamilymedecine, etc.), worldwide clinical guidelines, medical logic
Source UAE: UAE clinical guidelines (mohap.gov.ae,
doh.gov.ae/en/ resources/guidelines), worldwide clinical guidelines (UpToDate, MedScape), medical logic
Source UAE: UAE clinical guidelines (mohap.gov.ae,
doh.gov.ae/en/ resources/guidelines), worldwide clinical guidelines (UpToDate, MedScape), medical logic
Therapeutic duplication
(based on ATC drug classification)
(based on ATC drug classification)
Source: ATC drug classification
(https://www.who.int/tools/atcddd- toolkit/atc-classification)
(https://www.who.int/tools/atcddd- toolkit/atc-classification)
Who trusts us
Romania Business case
We’ve been given a dataset for 2 months period of medical services reimbursed by one of the big Health Insurers.
Case study
Health. Advanced Health Analytics
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