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  • Continue to walk through the Use Case and the parking lot, we will present this at the Friday meeting with the larger group and look to put it in a more formalized document
  • Use Case #1
    • Objectives:
      • Out of pockets costs are not always consistent across payers (some include deductibles and some do not)
        • Does not likely matter for consumer, but may matter for provider
        • Should the cost to the patient be made clear that it is an estimate?
          • Provider tools usually have a disclaimer that it is an estimate at the point and time
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    • Formulary/benefit (covered or not)
      • Includes a specification for why it is not covered
    • Lowest price alternative, which includes cash price (GoodRx)
  • Pre-conditions
    • Appreciates incorporating the SMART workflow, but Humana does not know how it would do 1 and 2
    • For Humana, they are not sure they could authenticate through a UN/PW in a health plan portal
    • Could the patient scan their insurance card to determine which PBM and plan is?
      • Workflow: Using GoodRx app, a consumer with Humana, could look at cash price and check their benefit
        • GoodRx would need to know who their insurer is, and the only way to do that is through your medical card: Vin PCN, Name, Medical Number are required to authenticate for RTPBC
        • Another option would be for the patient with a Humana portal to connect (they are already authenticated by logging into the portal)
    • All payer solution: every payer would stand up their own API with a PW/UN portal would be better
    • For GoodRx you would not need to authenticate, you just need NDC and location, do not need an additional step
    • We will continue to discuss this, but the SMART workflow was preferred
    • Prescription is made at point of prescribing and the consumer chooses preferred app no integration with EHR
      • Future option: the user through a 3rd party app connects to the EHR to get the data and then they would know you were getting a prescription
  • Use case trigger
    • Consumer is looking up a prescription price and/or formulary/benefit information and potentially a location to dispense their prescription; there is no EHR integration assumed
  • Main Consumer Workflow
    • Consumer chooses the app
      • Allows for the management of medication list
      • Has the ability to access the consumer facing RTPBC
      • No alert is sent
    • App manages the medication list or allows for medication look up feature
    • Consumer enters the name of the drug and app displays the OOP cost info
      • RxNorm is not supported by PBMs or GoodRx
      • Can map, but it is not 1 to 1, so the user would need to enter in additional information to map it to the right NDC
        • Could have a designated NDC per Rxcode
    • PBM will return the appropriate information
      • Prescription norm, representative NDC, actual NDC, current RTPBC data      
    • GoodRx will return cash pricing information per pharmacy
      • Will be based on the 3rd party app’s use of geolocation or zip codes or preferred pharmacy
  • Parking Lot
    • Manufacturer discount
      • Do we include the patient co-pay programs or discount coupons?
    • Removed the GoodRx cash price and NDC parking lot ideas
    • Provider NPI
      • Need to make this easy for the app to get the provider NPI information
      • The NPPES file could be used which is publicly available
  • Meeting invite every other week
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