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Specialty pharmacy round robin

Komodo Care Connect has the ability to assign specialty pharmacies to care plans in a round robin manner to ensure that programs do not favor one specialty pharmacy over another. The only exception is if a coverage investigation dictates certain factors that limit or identify which specialty pharmacies can be assigned.

Note

To use the round robin functionality in Komodo Care Connect V2 and above, users must be assigned the KCC - User - Specialty Pharmacy Round Robin (PJN_User_Specialty_Pharmacy_Round_Robin) permission set, which is in the MVN User (MVN_User) permission set group. To manage and configure the round robin functionality, admin users must also be assigned the KCC - Admin - Specialty Pharmacy Round Robin (PJN_Admin_Specialty_Pharmacy_Round_Robin) permission set, which is in the MVN Admin (MVN_Admin) permission set group.

To use the round robin functionality in Komodo Care Connect V1, users must be assigned the KCC - Editable Permissions (PJN_Editable_Permissions) permission set so they can view and use the PJN_Pharmacy and IndustriesPayer Account record types. To configure the round robin functionality, admin users must also be assigned the KCC - SP Round Robin Admin (PJN_SP_Round_Robin_Admin) permission set.

Configuration

To configure and enable the round robin functionality, an active care plan with at least one member plan and one coverage investigation must exist. Admin users then need to:

  1. Create an Account record of IndustriesPayer record type. This will represent the payer account.

  2. Create an Account record of PJN_Pharmacy record type. This will represent the specialty pharmacy account.

  3. Create a Care Program Specialty Pharmacy (mvn__PJN_Care_Program_Specialty_Pharmacy__c) record. This will represent the relationship between the program and the specialty pharmacy created in step 2.

  4. Create a Payer Specialty Pharmacy (mvn__PJN_Payer_Specialty_Pharmacy__c) record. This will represent the contracted relationship between the payer created in step 1 and the specialty pharmacy created in step 2.

Once configured, users can click SP Round Robin (PJN_SP_Round_Robin), which is managed by the PJN_InvestigationSPRoundRobinQuickAction Lightning Component, in the highlights panel of the PJN Coverage Investigation page layout to run the round robin functionality.

Assignment

The round robin functionality does the following:

  1. Query all of the pharmacies associated with the program via the Care Program Specialty Pharmacy (mvn__PJN_Care_Program_Specialty_Pharmacy__c) junction object.

  2. Check the mvn__PJN_Filter_Round_Robin_by_Payers__c field on the parent Care Program (CareProgram) record. If Filter Round Robin by Payers equals true, only specialty pharmacies that are linked to the highest order covered member plan on the coverage investigation are considered. For example, if a patient has Plan A as her primary member plan and Plan B as her secondary member plan; if the program has Pharmacy 1, Pharmacy 2, and Pharmacy 3 as their contracted specialty pharmacies; and the payer of Plan A is associated with Pharmacy 1 and Pharmacy 3, only Pharmacy 1 and Pharmacy 3 are eligible for the round robin assignment. If Filter Round Robin by Payers equals false, however, all specialty pharmacies are considered.

  3. Of all the (remaining) specialty pharmacies, select the specialty pharmacy that has the oldest time stamped on the mvn__PJN_Last_Round_Robin_Assign_Date_Time__c field on the Care Program Specialty Pharmacy record.

  4. Update the following associated records:

    1. Set the mvn__PJN_Last_Round_Robin_Assign_Date_Time__c field on the Care Program Specialty Pharmacy record to NOW

    2. Set the mvn__PJN_Selected_Specialty_Pharmacy__c field on the Coverage Investigation (mvn__PJN_Coverage_Investigation__c) record to the Account record representing the selected specialty pharmacy

    3. Set the mvn__PJN_Specialty_Pharmacy_Selection_Reason__c field on the Coverage Investigation record to Round-Robin

    4. Stamp the following information onto the PJN_Special_Pharmacy_Round_Robin_Audit__c field on the Coverage Investigation record to maintain an audit log of why the selected specialty pharmacy was assigned:

      • the date and time of the current round robin assignment (i.e., step 4a)

      • the available specialty pharmacies associated with the program via the Care Program Specialty Pharmacy record (i.e., step 1)

      • the value of the mvn__PJN_Filter_Round_Robin_by_Payers__c field on the Care Program record (i.e., step 2)

      • whether an Account record representing the payer is associated with the Member Plan (mvn__PJN_Member_Plan__c) record on the Coverage Investigation Item (mvn__PJN_Coverage_Investigation_Item__c) record

      • the payer on the member plan

      • the specialty pharmacies associated to the payer via the Payer Specialty Pharmacy (mvn__PJN_Payer_Specialty_Pharmacy__c) custom object

      Sample audit log for round robin functionality