Prescription Claims Processing:

ProAct Pharmacy Services provides a comprehensive real-time, on-line claim processing, adjudication and reporting system. Upon entering a participating pharmacy, the covered member presents their ID card along with a valid prescription. The pharmacy enters the data into the pharmacy’s computer system and the claim is transmitted to our host computer.

Claims submitted online, at the point-of-sale are instantly adjudicated using over 500 system edits including verification of benefit design restrictions, and eligibility status. This data is used to approve or reject claims online at the point-of-sale, as well as to adjudicate submitted paper claims. If the claim passes the edit process, the system determines the co-pay based on the Client’s plan-specific edits, and the claim is approved.

If the claim does not pass the edit process, corresponding information or a rejection message is returned to the pharmacy explaining the edit failure. Examples of return messages for rejected claims include “plan limitations exceeded” “drug not in formulary,” “non-matched cardholder ID,” “duplicate claim,” or “drug interaction.” ProAct also has the ability to customize a free-text message to the pharmacy based on the Client’s requirements. Regardless of which pharmacy a member uses, all of the information is processed through the ProAct system. This not only protects the member, it also prevents fraud and possible medication abuse.

Client and Customer Service:

ProAct Pharmacy Services is committed to the highest possible levels of client and customer service. Our program includes:

• Comprehensive, Smooth Implementation Process
• Assignment of a Dedicated Account Representative to each client
• Full Service Helpdesk with toll-free number
• Extensive network that includes 59,000 pharmacies nationwide, both chain and independent (see pharmacy locator)
• Drug Utilization Review – Concurrent and Retrospective
• Clinical Services and Wellness Programs
• Extensive Reporting Capability
• Comprehensive Auditing and Fraud Detection Program
• Quarterly Review of Plan with ProAct Representative – including recommendations for plan benefit changes
• Flexible Plan Design Options
• Informative Newsletters

ProAct’s program offers extensive flexibility in terms of the design of the plan benefits. Co-payments may be percentages or fixed dollar amounts. Three tier co-pay designs can also be accommodated. Days’ supply limitations are available as well as up front deductibles, annual maximums, and inclusion of mail service and specific benefit limitations.

ProAct maintains a therapeutic formulary for client use. However, with our flexibility, the client’s specific needs and requests can always be met concerning benefit design and formulary management.

ProAct Pharmacy Services, Inc. is a full service prescription benefit management company, providing the latest in pharmacy benefit management technology while also providing excellent local client and customer service.

To request more information on ProAct’s services please send an email to:

Maggie Cook
maggie@proactrx.com