Workers’ Compensation Cost Containment and Pharmacy Benefit Management (PBM) Services

Services to manage the State and the Special Fund’s Workers' Compensation Cost Containment Program (24/7 Nurse Triage (the State only), Utilization Review, Bill Review and PPO Networks), and Pharmacy Benefit Management (PBM) as described below:
- 24/7 Nurse Triage – To receive calls from injured workers or agency representatives to provide a medical recommendation to the injured worker for the most appropriate level of care for the initial evaluation and/or treatment of an industrial injury. A follow-up call is required the next business day to establish the outcome and if evaluation and treatment is needed beyond first aid. If the
injured worker has already received care then the service is not provided.
- Bill Review and PPO Networks – Bill review in accordance with the Arizona Fee Schedule, PPO network agreements, Usual and Customary guidelines, and preoffered discounts to the State from healthcare providers. Bill review organization will work with the Program to develop code based, rule-based bill review in accordance with the ODG Treatment Guidelines adopted by the ICA and best ractices for medical bill review adjudication. Bill review adjudication and eligibility for medical services for the associated claim is the responsibility of the bill review organization.
- Pharmacy Benefit Management (PBM) – Pharmacy benefit management services including, but not limited to: retail network management, mail order fulfillment and claim adjudication, auditing, account management, eligibility and implementation support, billing management, rebate management, formulary management, clinical program / utilization management, benefit modeling and analytics, and client reporting (standard and ad hoc). There will be no service charges to the State of Arizona for Pharmacy Benefit Management.