Standards of Care
Diplomat offers condition-specific management to help patients when they need it most throughout their journey. Different medications require different levels of resources. That is why our Standards of Care vary from therapy to therapy. We support efforts to achieve positive patient results by offering customized models of service.
Patient prescriptions are received into Diplomat through the intake process. Through this process, prescriptions are entered into the dispensing system, where Diplomat will verify insurance eligibility.
Benefits Investigation (BI)
Diplomat uses available resources to investigate and determine coverage for the prescribed medication. This may include adjudicating a test claim and contacting the insurance carrier. The prescriber will be informed throughout the process, including if prior authorization or coverage determination is needed.
- Patient Counseling Diplomat will provide standard written patient education (no product marketing) to patients for all medications dispensed. Patient assessments and related clinical patient management activities — all clinically objective — will also be performed.
Specialty medications are dispensed pursuant to a prescription in accordance with applicable law. Diplomat coordinates with a third-party carrier to facilitate delivery per the patient’s or prescribing physician’s instructions.
Additionally, certain nominal ancillary supplies (e.g., syringes, needles, alcohol swabs) and certain related items that might be necessary or useful in administering the specialty medication will be provided by Diplomat.
- Refill Program Patients with valid prescriptions will receive calls from Diplomat to determine need, in accordance with the dosing prescribed by the physician. Diplomat places calls to patient for refill reminders and manages ongoing medication orders, insurance follow-up, well patient check, inventory management and related, ongoing delivery coordination.
- Prior Authorizations (PA) Diplomat will provide support with all levels of authorization, including the initial request and subsequent renewal. When possible, Diplomat will eliminate unnecessary burden on both the prescriber and the patient by obtaining, facilitating, tracking, and completing PA criteria. Diplomat will leverage clinical support to ensure all relevant information is included in the initial request. Leveraging clinical support helps prevent unnecessary delays due to missing information. Diplomat will communicate with all stakeholders throughout the process to relay the most up-to-date information to the appropriate parties. Diplomat will consult with physicians and work to maintain prior authorizations. Prescribing physicians are provided information to facilitate patient coverage appeals.
- Appeal Support Diplomat will work with the payer to determine any payer-specific medical necessity documentation that might be required to support an appeal. If support is required, Diplomat will work with the prescriber to complete those forms. To secure reimbursement for the product/service in question, Diplomat will collect all necessary patient-specific information; support therapy trials; and package inserts to provide to the third-party payer. Once the signed documentation has been forwarded to the payer, Diplomat will continue to work with the payer until a decision is reached to approve or deny. At the same time, Diplomat will keep the prescriber and patient (where appropriate) aware of the claim status.
- Injection-Site Training Diplomat will provide phone-based reinforcement of injection-site training when requested. Diplomat will coordinate with third-party nursing services or manufacturer support of in-home nurse injection training.
- In-Home Nurse Support Diplomat coordinates home nurse support for patients needing additional assistance beyond a home or office nurse’s injection training.
- Manufacturer Copay Assistance Diplomat will provide support to patients, helping enroll them into manufacturer copay assistance programs if eligible.
- Funding for Part D & Other Government Programs Diplomat will work directly with the patient and/or prescriber to determine if the patient meets the pre-established guidelines for 501(c)(3) foundation assistance programs. If the patient does not meet the guidelines, Diplomat will facilitate enrollment into an alternate fund (e.g., manufacturer PAP) and will follow up with the patient and/or prescriber to obtain documentation necessary to complete enrollment. All applications are then submitted directly to the foundation for approval and monitored until a determination has been reached.
- Welcome Calls Diplomat will ask questions provided by the manufacturer during the welcome call for all direct referrals (i.e., directly referred by physician, healthcare provider, or patient). The manufacturer will notify Diplomat when certain questions should be implemented. Diplomat and the manufacturer will determine the amount of preparation time Diplomat will have after the effective date to provide this enhanced service.
- Disease, Product & News/Events Information Diplomat will provide manufacturer-provided printed materials to patients when starting a new therapy, if available. Diplomat will be given written advanced notice by manufacturer before mailings are to be sent.
- Patient Education Diplomat will provide enhanced education beyond core patient counseling, to be priced based on mutually agreed-upon educational components.
- Prescriber Education Diplomat will provide enhanced education beyond usual and customary pharmacy peer-to-peer education for prescribers, to be priced based on mutually agreed-upon educational components.
- Continuity of Care/Rescue Program Lapses in therapy prompt efforts to determine causes and re-initiate care. Service to be priced based on mutually agreed-upon business requirements.
No-Go Prescription Coordination
The goal of this value-added service is to increase the percentage of no-go prescriptions that will eventually be fulfilled. Specific services to achieve this include complete benefit investigations; prior authorizations; third-party financial assistance; referral triage and transfer to preferred pharmacy; reporting on no-go prescriptions, reason for no-go, and where prescription was transferred (to be priced based on mutually agreed-upon business requirements).
- Transfer to Mandated Hub When necessary, Diplomat forwards the prescription on to the appropriate hub and follows up with the prescribing physician.
- Transfer to Mandated Specialty Pharmacy If Diplomat cannot process a prescription, a patient care coordinator will forward it to the appropriate contracted specialty pharmacy and follow up with the prescribing physician.
- Customized Services We may contract with a partner to provide additional services beyond the Standards of Care listed above or amend, based on the drug class, a specific therapy or group.