Managing the rising costs of specialty infusions, especially in oncology, is a significant challenge for self-funded and level-funded employers. That’s where our Medical Infusion Carveout (MICO) solution comes in. Keep reading for a comprehensive look at the MICO program and some frequently asked questions (FAQs).
Key MICO Insights:
Our MICO solution offers several unique features and benefits to help employers manage costs:
- Fully Integrated Care Advocacy: Our program ensures a seamless, white-glove experience for members, with a dedicated advocate guiding them through the entire process.
- Three Cost-Reduction Levers:
- Manufacturer Assistance Programs: Helps members qualify for needs-based assistance, reducing medication costs.
- Specialty Pharmacy Dispensing: Uses our preferred Specialty Pharmacy to provide high-cost medications. MICO covers 275 high-cost medications through this pharmacy.
- Cost-Plus Model: Allows providers to submit claims directly to the Specialty Pharmacy for reimbursement, adding a small margin to cover their costs.
Additionally, MICO helps address the challenge of the rising cost of oncology drugs, which have seen a double-digit increase in the PMPM (per member per month) spend.
MICO FAQs: Your Questions Answered
Q: What is a Medical Infusion Carveout (MICO)?
A: MICO is a program designed to reduce the costs of high-cost specialty infusions by leveraging manufacturer’s assistance programs, specialty pharmacy dispensing, and a cost-plus reimbursement model.
Q: How does the fully integrated care advocacy work?
A: Each member is assigned an advocate who serves as a single point of contact throughout the entire process. This advocate liaises between the member, their provider, our prior authorization team, and our clinical pharmacy team to ensure a smooth and expedited experience.
Q: What types of medications are covered under this program?
A: The program targets high-cost specialty infusions including oncology drugs, rheumatoid arthritis treatments, and multiple sclerosis medications. The program covers up to 275 different medications.
Q: What if a member does not qualify for manufacturer’s assistance?
A: If a member does not qualify for manufacturer’s assistance, we can utilize our Specialty Pharmacy to dispense the medications or the cost-plus model to ensure the provider is reimbursed at their cost plus a small margin.
Q: How does the program handle urgent treatment needs?
A: The prior authorization process can be expedited to ensure there are no delays in care. Our clinical team works quickly to engage with providers and set up the necessary treatment protocols, even if it means working on the back end to finalize details.
Q: Is the MICO program available nationwide?
A: Yes, the MICO program is available to employers across the United States. There are no restrictions based on the employer’s location.
Q: What happens if a provider does not want to engage with the program?
A: Providers are encouraged to participate through clear communication and the use of prior authorization letters. If a claim is submitted outside of the program guidelines, it will be denied with an explanation, prompting the provider to engage with the Specialty Pharmacy.
Q: How can TPAs help self-funded health plans with MICO?
A: Third-Party Administrators (TPAs) like HealthEZ can help self-funded health plans by facilitating the implementation of the MICO program, ensuring proper claims submission, and leveraging their expertise in managing specialty infusions to maximize savings.
Q: How can employers get started with the HealthEZ MICO program?
A: Employers can request a savings analysis by providing specific claims data, including J codes, NDC codes, and dosage information. This analysis helps determine potential savings and the best program setup for their needs.
The MICO program provides an effective solution for employers to manage the rising costs of specialty infusions. By offering fully integrated care advocacy and multiple cost-reduction strategies, MICO ensures that members receive the care they need without financial strain.
For more information or to see how the MICO program can benefit your organization, feel free to get in touch.
Contact Us: https://healthez.com/contact/