Pharmacy Case Study

Situation
Previously, members on self-funded plans have had pharmacy benefits that do not cover certain expensive self-injectable medications. If these injectables are obtained at retail pharmacies, members are required to pay the entire bill up-front at the pharmacy. Members then must submit a receipt to the DAKOTACARE claims department for reimbursement.

Solution
For convenience and cost savings, these members are now referred to specialty pharmacies or home IV infusion providers. These providers will work with the member and then automatically bill DAKOTACARE directly under medical benefits for these injectable medications.

Because DAKOTACARE  recognized an opportunity to provide added member benefits, patients don’t have to pay the entire amount up front and all paperwork is handled internally, saving the member time and the plan reimbursement costs.