Benefit Management (PBM)

Prescription drugs continue to comprise a large portion of the total workers' comp spend.

They are also often the payer’s first point of visibility into an injured worker’s medical activity, representing an important opportunity to impact a claim’s trajectory. Identifying and avoiding potential missteps can mean the difference between a rapid return to health – and to work – or reduced function, poor quality of life, and thousands of unnecessary dollars.

Less than 10% of workers' comp claims receiving rx drugs account for over 60% of total pharmacy spend

Healthesystems’ PBM program provides proactive control over prescription drug activity from the moment an injured worker enters the pharmacy and enables better management throughout the entire continuum of care with:


An easy-to-use web portal tool that facilitates efficient and insightful management of prescription activity


Advanced data analytics for early detection and population triage


Integration and application of clinical services intervention to manage risk


Connectivity with service partners to connect patients with appropriate care


Ongoing program monitoring to drive continuous quality improvement

Powerfull Technology

Healthesystems’ integrated platform provides ease-of-use for the end user in navigating prescription activity among their claims, while driving relevant and right-time information into the decision-making process for a more effective and efficient claims process, which:

  • list-iconAutomates workflows to improve efficiencies and integrates all necessary claims stakeholders
  • list-iconImproves adherence to formulary recommendations
  • list-iconReduces friction and delays at the pharmacy counter
  • list-iconReduces out-of-network activity
  • list-iconExpedites dispensing of appropriate therapy
  • list-iconReduces end user frustration
  • list-iconPositively influences patient outcomes

Clinical Advantage

Prioritizing the best interest of the patient and basing decisions on sound, evidence-based clinical knowledge is the surest way to restore injured workers to good health and quickly return them to work.

Our full-service clinical program leads the industry, beginning with a depth of in-house pharmacology and occupational health knowledge embedded within the tools and workflows included in our technology platform and service delivery.

All customers are assigned a clinical pharmacist who provide:

  • list-iconReduces out-of-network activity
  • list-iconExpedites dispensing of appropriate therapy
  • list-iconReduces end user frustration

Actionable Data

We manage the most comprehensive dataset in the industry, offering market-leading capabilities to deliver program, population, and patient-level insights that:

  • list-iconShape overall pharmacy program customization to account for customer-and population-specific needs
  • list-iconDrive continuous quality improvement
  • list-iconProvide ongoing monitoring for opportunities to improve program effectiveness through operational and/or clinical enhancements
  • list-iconInform therapy decisions and intervention opportunities at the claims, pharmacist and prescriber levels

Data should be:


PBM Program Features

  • Best-in-class national pharmacy network including over 65,000 retail stores plus an extended network of non-retail dispensing options
  • Fully integrated retrospective bill processing and conversion program, including electronic connectivity with 3rd-party billers, allowing ALL bills to be adjudicated applying the same rules and edits
  • Highly efficient and effective automated prior authorization workflows
  • Dedicated regulatory & compliance team which monitors, reviews, reports and advises about legislative and industry changes
  • Advanced analytics and data visualization tools to monitor patient care, identify opportunities, and benchmark program performance
  • Clinical Concierge program providing consultation and decision support for optimal patient care
  • Clinical intervention services, including prescriber, provider and patient outreach Opioid management program to identify, reduce, and eliminate risk factors
  • Drug regimen review services from dedicated pharmacists with extensive workers’ comp experience
  • Client-tailored formulary and plan design
  • Step therapy protocols to ensure appropriate and cost-effective treatment
  • Highly effective fraud, waste and abuse program using real-time adjudication to identify potential abuse before script is filled
  • Customizable first fill program available 24 x 7 x 365