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High Deductible Health Plans

MBRx provides HDHPs a unique market strategy and competitive advantage that exceeds 100% copay expectations by addressing high deductible pharmacy problems and meeting the needs of pay-for-performance plans.

High Deductible Health Plans (HDHPs) function as a cash discount card that automatically converts to a cost-sharing arrangement once the deductible has been satisfied.  As a partial 100% copay plan, patients are completely vulnerable to pharmacists circumventing the adjudication process before the deductible is met, with the pharmacist experiencing very little risk of the action being detected.  Additionally, according to an article by Francois de Brantes, Executive Director, Health Care Incentives Improvement Institute, “More than half of all insured Americans spend less on health care during the course of any year than the total amount of the deductible, meaning these consumer-patients are in a full retail market.”  So, for HDHPs, including CDHPs, prior to patients meeting their deductible, their prescription drug card functions just like a cash discount card.


When pharmacies circumvent the adjudication process by reversing the claim, the following problems are experienced:


  • Patients are paying more than their PBM negotiated discount rate for their prescriptions;


  • Drug therapy related problems such as drug interactions, duplicate therapies, etc. are not detected and avoided;


  • Deductibles are not tracked at the point of service, thereby precluding appropriate cost-sharing copays when otherwise applicable;


  • Claims are not being counted toward the patient’s deductible; and


  • Data required for accurate actuarial and clinical analysis, risk prediction, projected outcomes and optimal compensation under pay-for-performance models is compromised.

A PBM RFP minimum standard criterion should address the top PBM problems that include inappropriate prescription claim reversals and prescription claim adjudication circumvention.

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The MBRx Patient Driven Rx℠ medical banking solution provides a real-time, quality control feature that forces claim adjudication by removing the pharmacist’s ability to unilaterally reverse a claim, thereby:


  • Ensuring the patient never pays more than the correct, aggressive, deep discounted price;


  • Providing concurrent DUR on all prescriptions, thereby reducing the potential for dangerous, and even life threatening, drug-related medical problems;


  • Eliminating the frustrating experience of being overcharged and waiting for the CDHP to provide corrective reimbursement;


  • Eliminating the uncertainty of knowing that the claim went toward their deductible; and


  • Assures accurate data because all prescription data are captured, thereby facilitating accurate actuarial and clinical analysis, risk prediction, projected outcomes and optimal compensation under pay-for-performance models.


Once provided an alternative, HDHPs, CDHPs and their members can be expected to refuse to be vulnerable to the deficiencies of traditionally administered pharmacy benefit plans and will select the PBM that offers the protection provided by the Patient Driven Rx℠ medical banking solution.  The problems the Patient Driven Rx℠ addresses can be used as a “wedge issue” by PBMs, HDHPs, and CDHPs to win business because, when presented with a choice, groups and consumers can be expected to select the firm that best protects their interest.


Obviously, early adopters will secure the most significant competitive advantage.


MBRx provides financial services for PBMs to give PBMs a unique PBM service differentiator and increase the PBM value proposition
The MBRx outsourced PBM payment service provides 100% copay safeguards by forcing claim adjudication thereby reducing pharmacy program vulnerabilities.
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