Friday, December 26, 2014

Biologics: An Overview

Intelligent Solutions in Pharmacy Benefits
612 Wheelers Farms Road, Milford, CT 06461
(888) 797-2479

By definition, biologics are medical products that are made from natural sources such as a microorganism, a human or an animal. Unlike other drugs that are made through a chemical process, biologics are manufactured in a living system and are usually very large molecules or mixtures of molecules that can not easily be identified. 

Just like other pharmaceutical drugs, biologics are used for the purpose of treating a medical condition or disease. Since biologics have proven to be an adequate solution for the treatment and prevention of some medical conditions, it is expected that over the next decade, the global biologics market will grow tremendously. In fact, at this rate, it is anticipated that by 2018, about 45 of the top 100 drugs will be biologics, pulling in about 50% of sales for that group of drugs.

When discussing biologics, it is also important to touch on their relationship with biosimilars and analyze how the growth of biologics will impact the production and growth of biosimilars as well. First and foremost, a biosimilar is any biological product that is very similar in nature and composition to an already licensed biological product. However, since biologics are extremely complex, it appears that it will be much more difficult for manufacturers to make a biosimilar version of originator biologics. Furthermore, in order to truly understand the safety and effectiveness of such biosimilars, manufacturers will need to carry out clinical trials where these drugs are tested. As a result, one can expect that biosimilar sales may not grow at the same rate as biologics since the process of integrating them into the market will be a much slower one.

At PBIRx, we are always following the latest pharmacy trends to better understand how the industry is changing. In turn, we are able to better analyze our clients' pharmacy benefit plans and develop solutions that are more in tune with the latest industry breakthroughs. For more information on biologics or to find out how we can help you with your pharmacy benefit plan, please visit us on our website or contact us at (888) 797-2479 today.

Wednesday, December 17, 2014

Generic Drug Costs Continue To Rise

Intelligent Solutions in Pharmacy Benefits
612 Wheelers Farms Road, Milford, CT 06461
(888) 797-2479

Although most conversations about healthcare revolve around the plans for it to be more affordable and accessible to those who need it regardless of their financial situation, the fact of the matter is that drug costs are still placing a strain on many of our wallets. Specifically focusing on generic drugs, which are typically a patient's "go to" drug in order to reduce their pharmacy costs, recent trends suggest that their costs have actually gone in a different direction - the wrong direction.

According to ABC News, the prices of more than 1,200 generic drugs increased at an average of 448% in just one year. Albuterol Sulfate, a medication to treat asthma, is just one example of a drug that has skyrocketed in price. As stated in the article, between October of 2013 and April of 2014, the cost of two tablets of albuterol sulfate increased from just $11 to $434.

So what's being done to control the costs, you ask? Last month, the New York Times reported that lawmakers met to discuss the options currently available to provide relief from the astronomical increase in prices. One solution that was focused on was the possibility of having some prescription drugs imported to the United States from other countries. That is because recent findings suggest that many brand name equivalents of generic drugs are significantly cheaper in other countries. Although the importation of drugs is typically frowned upon, some states, such as Maine, passed a law allowing residents to order prescriptions from certain licensed pharmacies in Canada, Britain, Australia and New Zealand. The drugs delivered to people by an international pharmacy come directly from the manufacturer in flat blister packs.

At this congressional hearing, Vermont Senator Sanders and Maryland Representative Cummings also proposed another solution which suggested that generic drug manufacturers be mandated to provide a rebate to Medicare and Medicaid if their prices increased at a rate faster than typical inflation. However, interestingly enough, the generic drug maker representatives invited to attend opted out, providing no support or explanation for the recent rise in costs.

For more information on the current rise in costs and how it is to be handled, be sure to follow us on Facebook and Twitter. As soon as we know something, you'll know something!

At PBIRx, our goal is to provide you with more control over your healthcare costs so that you're paying the lowest price possible for the pharmaceutical services you need. As the end of the year approaches, we recommend having your pharmacy benefit plan audited to determine if you're receiving the discounts and rebates you deserve as stated in your contract. For more information on how we can help, please give us a call at (888) 797-2479 today!

Monday, December 15, 2014

Pharmaceutical Terms Defined: Part 2

Intelligent Solutions in Pharmacy Benefits
612 Wheelers Farms Road, Milford, CT 06461
(888) 797-2479
In a recent blog, we defined five terms commonly used by members of our team in order to help you better understand our industry. Although those five terms will make reading pharmaceutical literature and understanding hot topics easier on your part, alone, they simply aren't enough. That is why today, we would like to introduce you to an additional five terms and their definitions! See below:

Prior Authorization (PA): The approval process/clinical criteria required in order to obtain particular drugs or certain amounts of others. Criteria is typically based on FDA manufacturer approved guidelines. As more expensive drugs are launched, this clinical criteria is expanding significantly, especially with Hepatitis C drugs.

Quantity Limit (QL): The quantity of medication that is recommended by the pharmaceutical manufacturer to be dispensed to a patient over a certain period of time at a particular copayment, coinsurance or deductible.

Rx: Symbol or acronym meaning "medical prescription."

Usual and Customary Price (U&C): The price that a pharmacy charges when there is no health insurance or other coverage for the purchase of prescriptions. This price varies from pharmacy to pharmacy on any given day.

Wholesale Acquisition Cost (WAC): The list price of a drug paid by a wholesaler, distributor or other direct account, before any rebates, discounts, allowances or other price concessions are offered by the supplier of such drugs.

Have you come across industry terms that you are still unsure about? Visit us on our Facebook or Twitter page and let us know! We would be pleased to provide you with the definition so you can better understand additional information on the topic you are seeking.

Since 1993, we have exclusively provided intelligent solutions to our clients in order to help them effectively manage their pharmacy benefit costs. Due to the combined effort of our actuaries, financial analysts, clinical pharmacists, attorneys, HIPAA Compliance Officers and other industry experts, we have found great success in finding our clients the rebates and discounts they deserve through their pharmacy benefit plans. For more information on how we can help, please visit us on our website or contact us at (888) 797-2479 today!

Friday, December 12, 2014

PBIRx's Role in Healthcare Reform Compliance

Intelligent Solutions in Pharmacy Benefits
612 Wheelers Farms Road, Milford, CT 06461
(888) 797-2479
The topic of Healthcare Reform, otherwise known as The Patient Protection and Affordable Care Act (PPACA), the Affordable Care Act (ACA) or even "Obamacare," is one that requires a lot of attention in the pharmacy and pharmacy benefit industry. Being that the first version of the law reads "The Patient Protection and Affordable Care Act," one may assume that this law has adjusted healthcare plans to be more affordable today than in the past. However, the nature of the law suggests that the desired level of affordability is still not where many hoped it would be.

A particular section of the Affordable Care Act that we would like to point out is Coverage of Preventive Services. There are specific terms and guidelines stated by the US Preventative Services Task Force (USPSTF), as to what preventive services must be covered under a patient's health plan and some of those services also include the coverage of certain pharmaceutical drugs at a zero copayment.

This is where PBIRx steps in! At PBIRx, one of our responsibilities related to the Affordable Care Act is to make sure that all of our clients are compliant with the USPSTF coverage of certain drugs for plans that are non-grandfathered. Thus, we carefully review our clients' current plan design of covered drugs and make sure that they accurately reflect the guidelines stated in the ACA and that such guidelines have been implemented appropriately with their PBM and communicated to our clients' members. But our services don't stop there! As we work towards making sure everyone is compliant with the law, we also make sure our clients have the necessary documentation such as a Summary of Benefits and Coverage available to their members.

The following is a list of preventative drugs often subject to certain criteria, which may include age and/or disease state, for which the USPSTF mandates a zero copay:
  • Aspirin to prevent cardiovascular disease for certain ages
  • Fluoride Supplements
  • Folic Acid
  • Iron Supplements
  • Vitamin D
  • Immunizations
  • Oral Contraceptives
  • Breast Cancer Preventive (plan renewals starting 10/1/14)
  • Aspirin for preeclampsia risk (plan renewals starting 9/1/15)
Furthermore, it is important to note that smoking cessation coverage is also included in the list of preventative drugs that the USPSTF mandates a zero copay for. However, since this coverage does not have a deadline, anyone that currently requests drugs or services to aid in this process at a $0 copay is given a "safe harbor" compliance status.

For more information on how PBIRx works to help with ACA compliance, please give us a call at (888) 797-2479 today!

Monday, December 8, 2014

Pharmaceutical Terms Defined

Intelligent Solutions in Pharmacy Benefits
612 Wheelers Farms Road, Milford, CT 06461
(888) 797-2479
In order to understand topics covered in the pharmaceutical industry, it is first important to understand the terms and acronyms that are used to detail them. Since the terms used by industry experts can be quite complex and highly specific, it is often difficult to decipher their meaning at first glance. However, not understanding such terms makes it much more difficult to fully grasp industry news as well as information pertaining to your healthcare and pharmacy benefit plans.

To help you better understand our industry, we've put together a list of five terms commonly used by our team along with their definitions; check them out below!

Average Wholesale Price (AWP): Average wholesale price for a drug that is determined by the manufacturer and applied to each NDC code. The AWP does not necessarily reflect what pharmacies pay for a drug, but it is generally accepted as a pricing measure.

Generic Effective Rate (GER): The rate calculated by looking at the AWP of a generic drug as well as all generic drug claims submitted for a specific plan.

Maximum Allowable Cost Price (MAC): When brand drugs have more than one generic equivalent, prices will differ among each depending on manufacturer and package size. The MAC for such drugs is determined and implemented by your Pharmacy Benefit Manager. Some brands also have a MAC applied i.e brand with two distributors.

National Drug Code (NDC): The code every FDA approved drug is assigned, which could be 10 to 11 digits. The first 4-5 digits represent the Labeler Code (manufacturer, repacker or distributor), the next 3-4 digits represent the Product Code (strength, dosage form and formulation), and the last 1-2 indicate the Package Code (package forms and sizes).

Patient Protection and Affordable Care Act (PPACA): Also known as Obamacare and the Affordable Care Act, PPACA is a federal regulation that was signed into law by President Obama on March 23, 2010, with several amendments to date.

Though these are just a few of the most popular pharmaceutical terms, they are a great place to start to increase your knowledge and understanding of this industry. Stay tuned for our next blog which will contain an additional five!

At PBIRx, it is our goal to make sure our clients are fully educated on their pharmacy benefit plans, which is why we take the time to explain what it all means, every step of the way. With us, there is no confusion or uncertainty when it comes to your healthcare costs. To learn more about how we can help, please visit us on our website or contact us at (888) 797-2479.

Friday, October 31, 2014

PBIRx Quarterly Staff Meeting: A Behind the Scenes Look

Intelligent Solutions in Pharmacy Benefits
612 Wheelers Farms Road, Milford, CT 06461
(888) 797-2479

Held on October 2, members of our corporate office and satellite offices came together to discuss a variety of important topics and even have a little bit of fun! First, we began with a detailed analysis of our technology, then moved into updates about our clinical algorithms and specialty drug toolbox. From there, we took a look at our marketing efforts and plan for the next few months. We carefully examined our goals, achievements and opportunities from our first three quarters, and set goals for the fourth.

But that's not all! We ended the day with a fun team building experience.

At PBIRx, we believe that it is important for our employees to maintain close professional relationships. Thus, it was important to us as a Company to individually share our vision for the future. 

For our event, we made teams and each team created a vision board to outline where they thought the Company should be headed for the future. Each team created a completely different vision board but, there were three commonalities in their positive thinking: Company, Clients and Community.

PBIRx is a leading auditing and consulting firm located in Milford, CT that specializes in pharmacy and pharmacy benefit solutions. We provide a high level of customer service, with unbiased and objective financial analyses, while always focusing on our clients' best interest rather than the PBM. Our goal is to achieve an optimum healthcare outcome at the lowest possible cost for the client and member. For more information on our services and how we can help you with your pharmacy benefit plan, visit us at or give us a call at (888) 797-2479 today!

How Can PBIRx Help You?

Intelligent Solutions in Pharmacy Benefits
612 Wheelers Farms Road, Milford, CT 06461
(888) 797-2479

Since 1990, PBIRx has been working to control pharmacy benefit costs and create optimal health care outcomes for employers, institutions and third party administrators who provide pharmacy benefits to their employees or members. Using proprietary algorithms and cutting edge technology, our esteemed group of consultants with years of experience in the pharmacy industry are dedicated to finding solutions for our clients that result in a reduction of their overall health care costs. In doing so, we make it our priority to make sure that each client is treated individually and a strategic plan is developed along with estimated savings based on specific agreed upon needs and goals. The original estimated savings is reported back to our clients on a quarterly basis to be sure that we are delivering the savings that we promised!

But how do we do it? At PBIRx, we offer a variety of services to aid in the management of your pharmacy benefits. As a leading pharmacy benefit auditing and consulting firm, our staff closely analyzes your current pharmacy benefit plan. Then, using a combination of the latest technology and our own proprietary programs, develops a strategy to reduce the cost without eliminating any of the benefits your employees or members are receiving at the time. Further, we constantly seek out clinical and other cost saving opportunities and work to make sure that the terms and discounts stated in your plan are an accurate and competitive depiction of the pricing options currently available in the industry.

See below for a comprehensive list of the services that we offer here at PBIRx:
  • Pharmacy Benefit Consulting
  • Pharmacy Benefit Auditing (AuditRx)
  • Pharmacy Benefit Actuarial Services
  • Third Party 340B Compliance Audits
    Allocation Rate Projections
  • Clinical Technology Intelligence and Algorithms
  • Rebate Aggregation
Since pharmacy benefit plans and the terms outlined within are extremely complex, changing often and difficult to navigate, it is important for entities to connect with an expert like PBIRx to make sure that their plans are designed in a way that produces only the best results for the entity and for those that they provide benefits for. Are you ready to get started? To learn more about our services and how we can help, please visit us at or give us a call at (888) 797-2479 today.

    Wednesday, October 29, 2014

    Connect With PBIRx On Social Media!

    Intelligent Solutions in Pharmacy Benefits
    612 Wheelers Farms Road, Milford, CT 06461
    (888) 797-2479
    PBIRx is a cutting edge technology driven auditing and consulting firm specializing in pharmacy and pharmacy benefit solutions. We work with several different entities requiring different solutions to manage health care costs including health plans, municipalities, third party administrators, employers and unions. With a diverse staff ranging from financial analysts to actuaries, attorneys, informatic statisticians, clinical pharmacists, programmers and HIPAA Compliance Officers, PBIRx carefully prepares a needs analysis and a variety of cost saving solutions always with the intent of optimizing the healthcare outcome at the lowest cost.

    Pharmaceutical industry laws and guidelines are ever changing along with the Affordable Care Act mandates. It is important for entities that provide an in house and/or pharmacy benefits to their employees or members to stay up to date with the latest rules and regulations. Furthermore, since pharmacy costs can represent up to 40% of total health care costs as the costs of both specialty and generic drugs increase, it is important to be aware of these changes on a continuum so that you can take action quickly to minimize added costs. Do you think that the Pharmacy Benefit Manager, which profits from the adjudication of claims and recommended formularies that increase "their" rebate profitably is always looking for YOUR best interest?

    When you follow PBIRx on social media, you can be sure that you will have all the information pertaining to pharmacy and pharmacy benefit management right at your fingertips! But where can you find us? Click on the following to visit us on each of our active social media sites:

    And don't forget! You can now SUBSCRIBE to our blog! When you enter your email address above, you will get a notification every time we publish a new blog to our page.

    For more information about PBIRx and how we can help, please visit us on our website or contact us at (888) 797-2479 today!

    Tuesday, October 28, 2014

    Generic Price Increases Results in More Plan Design Tiers

    Intelligent Solutions in Pharmacy Benefits

    612 Wheelers Farms Road, Milford, CT 06461

    (888) 797-2479

    Whether you are a manufacturer of generic drugs, a pharmacy that supplies generic drugs, or a consumer that relies on certain generic drugs, you are probably aware that the cost of generic drugs is increasing at a steady rate. According to the New York Times, over the past year alone, several generic drugs have more than doubled in price, and seemingly, the rate at which they are increasing does not seem to be slowing down. But what does this mean for those that interact with these drugs on a daily basis? While for some drug channels increasing costs have brought nothing but benefits; for others, the negative effects of generic drug inflation are much more prominent. 

    For generic and brand manufacturers as well as wholesalers, increased drug costs are not much of a concern. Why? For generic manufacturers, increased costs mean you are now selling the same drugs but at higher prices, therefore increasing profits. For brand-name manufacturers, shortages in generic drugs are leading consumers to their product, since lately many have shown to be less expensive than some of the more popular generic drugs. Lastly, many wholesalers are also benefiting from increased costs since increases in gross profit dollars and lifted revenue growth have come as a result of the change in price.

    Unfortunately, some pharmacies, third-party payers and consumers are not as lucky when it comes to generic drug inflation. Although some pharmacies will benefit from price increases over time, those that signed at-risk payer contracts are likely to see a decrease in profits as costs continue to rise. Similarly, third party payers are also experiencing the negative effects of generic drug inflation as it increases the cost of their pharmacy benefits. That means that third party payers must now allot more of their budget to cover generic drugs for each of their clients. Finally, since some plans offer multi tiers for generics, higher cost generic drugs now fall under a higher co payment tier and thus, out of pocket costs are increasing for the consumer, which could make it financially prohibitive for them to fill the prescriptions that they need.

    As the cost of generic drugs continues to rise, it becomes even more important for entities that provide pharmacy benefits to its employees or members to connect with an expert like PBIRx. PBIRx can analyze the generic drug mix for an entity and provide both optimum plan design recommendations and negotiate discounts resulting in a win-win situation. PBIRx works closely with all of their clients to create optimal health care outcomes for their members while minimizing overall health care costs. For more information on how PBIRx can help, visit us on our website or contact us at (888) 797-2479 today!

    Tuesday, October 21, 2014

    Pharmacy Benefit Auditing at PBIRx


    Intelligent Solutions in Pharmacy Benefits

    612 Wheelers Farms Road, Milford, CT 06461

    (888) 797-2479
    Since pharmacy costs represent nearly 40% of today's total health care costs, it is crucial for any entity that provides pharmacy benefits to its employees or members to audit all the financial discounts and guarantees stated in their PBM contract to be sure that claims are being adjudicated exactly as you agreed to in your PBM negotiations. 

    Furthermore, as the cost and utilization of specialty drugs continues to rise, it is even more important to make sure that the discounts negotiated are in accordance with the terms outlined in the signed contract including Limited Distribution Specialty Drugs and new drugs that come to market. 

    At PBIRx, it is our goal to make sure that the language, discounts and guarantees stated in our clients' contracts are being adjudicated accurately by the PBM, which is why we provide comprehensive pharmacy claims audits using our proprietary AuditRx® platform.

    AuditRx® presents our clients with a comprehensive written report with Exhibits to provide to the PBM. Additionally, our team of experienced actuaries and financial analysts have been very successful in negotiations with various PBMs resulting in significant monetary recoveries.

    The following is a brief description of the AuditRx® process, which can be annually, quarterly or monthly:
    • Facilitate delivery of all PBM claims data in an electronic format to PBIRx.
    • Format financial terms which are stated in the signed contract between the client and the PBM, into the AuditRx® platform.
    • Provide auditing results in both summary and detailed formats on the accuracy of information such as contracted brand/generic discounts, dispensing fees for retail, mail and specialty pharmacy along with administrative fees.
    • Review contract language related to PBM shared savings billing reconciliation and member co-payments in accordance with plan design and claims paid by ineligible members.
    • Provide eligibility audit to be sure that claims are not being adjudicated for members no longer eligible for pharmacy benefits.
    For more information on the AuditRx® program, visit us on our website or contact us at (888) 797-2479 today!

    Thursday, October 9, 2014

    Health Plan Identifier Requirements

    Intelligent Solutions in Pharmacy Benefits
    612 Wheelers Farms Road, Milford, CT 06461
    (888) 797-2479
    The Department of Health and Human Services (HHS) requires all health plans to obtain a ten-digit "unique identifier" from a government sponsored agency. Plans must use a Health Plan Identifier (HPID) to identify a health plan in standard Health Insurance Portability & Accountability Act (HIPPA) electronic transactions.

    Plans that are fully insured on the medical and self-funded on their pharmacy benefit are required to apply for an HPID.

    Key compliance dates to obtain the HPID are as follows:
    • Health plans, with the exception of small health plans, must obtain HPIDs by November 5, 2014.
    • Small health plans (annual receipts of $5 million or less) must obtain HPIDs by November 5, 2015.
    • All plans that generate electronic transactions are required to use the identifier in those transactions beginning November 7, 2016.
    The online application is available through the Health Plan and Other Entity Enumeration System (HPOES) housed within CMS' Health Insurance Oversight System (HIOS) and may be accessed through the CMS Enterprise Portal. Users will need to provide additional information to register in the enterprise portal and obtain a user ID and password.

    The application also requests a Payer ID or National Association of Insurance Commissioners (NAIC) number. CMS has advised that self-funded employers who do not have these numbers may enter "not applicable" in this field on the application.

    To learn more about the application process, you may view CMS' HPID and OEID overview presentation by clicking here. In addition, videos are available to walk through each step of the application process to obtain a HPID for a controlling health plan, a sub health plan and other entity identifier. See Quick Reference Guide to: Obtaining a Controlling Health Plan HPID.

    For more information, please contact PBIRx at (888) 797-2479 today!

    Wednesday, October 8, 2014

    Hydrocodone Classification Change

    Intelligent Solutions in Pharmacy Benefits
    612 Wheelers Farms Road, Milford, CT 06461
    (888) 797-2479
    For safety reasons, the U.S. Drug Enforcement Administration (DEA) has reclassified medications containing hydrocodone to a Schedule CII narcotic. In the past, medications that contained hydrocodone were considered controlled substances, but the classification was not as high. Effective October 6, the new classification means that a doctor can no longer include refills for these medications on prescriptions.

    So why is the DEA making this change? These changes are designed to minimize the misuse of these medications, while still making sure that patients with severe pain have reasonable access to the medications they need.

    And what does this mean for you? The following are a few important things to consider as of October 6, 2014:
    • Any remaining refills on current hydrocodone products will no longer be valid. You will need to see your doctor each time you need a refill for a written prescription. 
    • Your doctor will NOT be allowed to call in or fax hydrocodone prescriptions.
    • In some states, nurses or physician assistants will no longer be able to prescribe hydrocodone medications.
    Maxor sent out letters explaining this change to members who have had these meds filled at mail order within the last 90 days.

    Please note, however, that there may be some member disruption. Most pharmacists and doctors are aware of the new classification of hydrocodone and will be prepared for the change. As noted in the communication from Maxor, there has been ample notification of the impending change.

    This is an excellent class of drugs for treating pain; however, it is a highly abused drug class that is often diverted from its intended purposes and used for drug abuse. That is why we view it as a positive change to reduce unwarranted abuse of this class of drugs.

    For more information, please contact PBIRx at (888) 797-2479!

    Friday, October 3, 2014

    Meet The PBIRx Team: Robert Kademian

    Intelligent Solutions in Pharmacy Benefits
    612 Wheelers Farms Road, Milford, CT 06461
    (888) 797-2479
    At PBIRx, we have an outstanding team of actuaries, financial analysts, clinical pharmacists, attorneys, HIPPA Compliance Officers and experts in the pharmacy benefit management industry who, all together, help create optimal health care outcomes while minimizing overall health care costs for our clients. It is because of them that we are able to be a leading consultant in the Pharmacy Benefit industry, and therefore, we'd like for you to get to know them a bit better!

    Today, we'd like to introduce you to our Director of Strategic Accounts, Robert C. Kademian! Check out his PBIRx interview below:
    1. What is your full name and title at PBIRx?  Robert C. Kademian, Director, Strategic Accounts.
    2. How long have you been working with PBIRx? 6 years 
    3. What do your day to day responsibilities include? Client services – plan design, clinical recommendations, resolving member or client issues, member communications, and account reviews to show clients how their plan is doing. Involved in developing cost saving strategies for clients using the expertise and talent offered throughout PBIRx. I communicate options to clients, and help craft communication from clients to plan members.  I am also a member of the clinical team and take part in some sales meetings. 
    4. When did you first decide you wanted to work in the pharmaceutical industry? What about it interests you? I was always interested in how medicines worked as a child, and the roles of doctors, nurses and pharmacists.  I was so interested that I became a pharmacist, then worked for drug companies for over two decades. 
    5. What school did you attend and what did you get your degree in? B.S. in Pharmacy, with a focus on business from the Mass. College of Pharmacy and Allied Health. MBA with a focus on marketing from Boston College. 
    6. What has been your greatest achievement at work thus far?  Not really one that stands out. It is most likely how we now present and implement the clinical component of a client’s initial clinical plan. We are now able to move new clients from where they are when we start, to where they need to be, and do it as fast or slow as they want. I think it gives new clients a better picture of what we will be doing for them early in the relationship, which makes them feel more comfortable about having chosen to work with PBIRx.

      Note from PBIRx President: an integral part of  the PBIRx Clinical Department, Bob has enhanced our Clinical Program options resulting in thousands of dollars of savings for PBIRx clients. He has also been a leader for the staff being certified in Population Health Management providing additional information to everyone based on his years of experience.  Lastly, Bob has been instrumental in nurturing a team culture at PBIRx.

    7. Outside of work, what do you do for fun?  Family time and playing soccer are the first things that come to mind.  I also run, play tennis, and workout at the gym.  I also enjoy learning about business and business leaders – what great businesses have in common,  business principles, and biographies of business leaders.
    Big thank you to Robert for all of his hard work and dedication to PBIRx. We are so fortunate to have you on our team!

    For more information on PBIRx, visit us on our website or contact us at (888) 797-2479.

    Tuesday, September 30, 2014

    PPACA Requirements and MOOP As They Relate To Health Coverage

    Intelligent Solutions in Pharmacy Benefits
    612 Wheelers Farms Road, Milford, CT 06461
    (888) 797-2479
    Beginning with the plan year that starts on or after January 1, 2015, the Affordable Care Act (ACA) states that all non-grandfathered group plans are required to accumulate out-of-pocket expenses for Essential Health Benefits (EHB) across several benefit providers. For 2015, the Maximum-Out-of-Pocket (MOOP) is expected to be as follows:

    $13,200 for families
    $6,600 for individuals

    The Affordable Care Act, or Patient Protection and Affordable Care Act (PPACA), also mandates that certain preventive items and services must be covered at 100% within a patient's health plan. This means that such preventive items and services are to be excluded from deductibles or other cost-sharing limitations and covered with no member cost. Coverage is required one year after the U.S Preventive Services Task Force (USPSTF) has issued the new recommendation on the first plan year that starts after such one year date. The plan may use reasonable limits on the frequency, but not the dollar amount of preventive care that it will cover.

    Recently, Breast Cancer preventives and Preeclampsia prevention have been added to the list of services that are required to be available without falling subject to cost-sharing limitations. Please see below for some insight into each of these two preventive services:

    Breast Cancer Prevention:
    For those candidates who are at increased risk for breast cancer and at low risk for adverse medication effects, the USPSTF suggests that clinicians should prescribe risk reducing medications such as tamoxifen or raloxifen. Coverage is required on the first plan year effective date after September 24, 2014.

    Preeclampsia Prevention:
    By definition, preeclampsia is a complication that occurs during pregnancy that is characterized by high blood pressure and signs of damage to other organ system such as the kidneys. To prevent preeclampsia in high risk women, the USPSTF recommends the use of low-dose aspirin (81 mg/d) after 12 weeks of gestation. Coverage is required on the first plan year effective date after 2015.

    For a more comprehensive list of preventive services that are covered without cost-sharing or to learn more about the PPACA requirements that will affect non-grandfathered health plans starting next year, contact us at (888) 797-2479 today! At PBIRx, our consultants can provide you with a more detailed analysis about the items and services that are included under the Affordable Care Act and can educate you further on how to effectively manage your maximum-out-of-pocket costs through different plan options.

    Friday, September 26, 2014

    Specialty Drug Tool Box Spotlight: Clinical and Pharmacoeconomic Outcomes

    Intelligent Solutions in Pharmacy Benefits
    612 Wheelers Farms Road, Milford, CT 06461
    (888) 797-2479
    As a leader in pharmacy benefit management services, it is our goal to make sure that our clients fully understand the process we use to help them find the right solutions for their health care plan. In our most recent blogs, we focused on the first three components of the Specialty Drug Tool Box and today we will cover the fourth!

    The final piece of our tool box rests in clinical and pharmacoeconomic outcomes. Ultimately, this stage encompasses all that came before it by taking a closer look at the specialty drugs chosen and focusing on how both the patient and the disease will also be cared for and managed.

    Now that your plan is in place and your patients are provided with the medicine they need, it is crucial to make sure you are managing the patient's disease state as they begin to take the medication as prescribed. To be specific, this includes looking at coordination of care, medication adherence, side effect management and finally, disease management. 

    At PBIRx, we are currently piloting integration of specialty pharmacy and medical data using proprietary algorithms to provide actionable data. As you finalize the management of your pharmacy benefits with your PBM, we recommend asking about the different types of programs and reports that are available in order to demonstrate management of the disease in addition to just dispensing a specialty drug.

    By closely following the steps outlined in our proprietary Specialty Drug Tool Box, we believe that our clients will have found a solution that best fits their pharmacy benefit needs. Interested in experiencing it for yourself? If you're an entity that provides pharmacy benefits to your employees or members, we suggest connecting with one of our consultants today to enjoy all that our management services have to offer using cutting edge technology and proprietary algorithms. For more information, visit us on our website or contact us at (888) 797-2479 today!

    Wednesday, September 24, 2014

    Specialty Drug Tool Box Spotlight: Clinical Review and Management

    Intelligent Solutions in Pharmacy Benefits
    612 Wheelers Farms Road, Milford, CT 06461
    (888) 797-2479

    As we move forward with our proprietary Specialty Drug Tool Box, we come to the third stage known as clinical review and management. Now that you have decided which specialty drugs you will include in your pharmacy benefit plan, have agreed on competitive and auditable discounts, analyzed and chosen appropriate dispensing channel options for various high cost specialty drugs, it is time to look at your plan from a clinical perspective. You must be certain that the specialty pharmacy chosen has optimal, detailed, current and updated clinical criteria; a well established formulary; and a robust utilization management program for all high cost specialty drugs.

    This stage focuses on your plan's benefit design and looks at various clinical analyses and their ability to produce higher savings than just a discount on the cost. As you search for the best solutions, keep in mind that the co-pays for preferred, non preferred and biosimilar/generic drugs should always coincide with the analyses on efficacy, drug costs and rebates. Additionally, due to the sometimes toxic side effects, complex dosing and cost of specialty drugs, it is also imperative that the disease itself is managed, in addition to managing the drug that is prescribed to effect a positive and optimal cost health care outcome.

    As you work with your PBM to decide which solutions will be the most effective for your budget and the population of people you plan to provide benefits for, consider the following:
    1. Has your PBM worked with you to model and report different clinical programs and interventions and the associated savings? 
    2. Has your PBM shared their specialty drug prior authorization criteria to be certain that it is detailed, evidence based, robust and current?
    If you feel like these topics have not been covered, we recommend asking your PBM to dig deeper into their analysis so that you can be sure you have found the best solution for your pharmacy benefit plan.

    Do you need help managing the growing high costs of specialty drugs in your pharmacy benefit? Contact PBIRx today! Our mission is to create optimal health care outcomes while minimizing overall health care costs. For more information, visit us at or give us a call at (888) 797-2479 today!

    Monday, September 22, 2014

    Specialty Drug Tool Box Spotlight: Dispensing Channel Management

    Intelligent Solutions in Pharmacy Benefits
    612 Wheelers Farms Road, Milford, CT 06461
    (888) 797-2479
    Following along with our Specialty Drug Tool Box, the next category we focus on is that of dispensing channel management. In order to effectively manage high cost specialty drugs as part of your pharmacy benefits, you must first research and analyze all of the available dispensing channel options before making a decision on which option you will direct members to for each specialty drug. Since specialty drugs are only available for purchase at pre-determined specialty pharmacies or licensed distributors, you will have to decide which is the best for you to partner with based on not only, the array of discounts available, but also the clinical prior authorization protocol to be sure the drug is appropriate for the medical indication AND that the specialty pharmacy is managing the utilization to prevent wastage resulting in a positive healthcare outcome.

    There are several options to consider in regards to the dispensing of specialty drugs. The following is a list of a few channels that are available to provide you with the service you need:
    • Retail pharmacy
    • PBM owned specialty pharmacy
    • Doctor's office
    • In house hospital pharmacy
    • Infusion center
    • Limited distribution approved pharmacy
    • Niche specialty pharmacy that offers high touch patient services at similar discounts to the PBM owned specialty pharmacy
    At PBIRx, we suggest looking into each of these options in great detail since drug discounts, member management services and rebates vary based on the specific dispensing facility. Additionally, be aware that your PBM may only promote their own specialty pharmacy even when there are pros and cons to other dispensing options. That is why PBIRx suggests asking your PBM about the opportunities listed above, since they might satisfy your needs better than the pharmacy your PBM promotes.

    In order to find the right solutions for our clients, using proprietary algorithms, PBIRx diligently analyzes and audits all of the available dispensing options for high cost specialty drugs as part of our efforts to help you manage your pharmacy benefits. For more information on how we can help, visit us at or contact us at (888) 797-2479 today!

    Wednesday, September 10, 2014

    Specialty Drug Tool Box Spotlight: Pricing

    Intelligent Solutions in Pharmacy Benefits
    612 Wheelers Farms Road, Milford, CT 06461
    (888) 797-2479

    Here at PBIRx, we believe that it is crucial for our clients to fully understand the nature of pharmacy benefits and how to approach their cost and other associated health care outcomes. In our previous blog, we highlighted our proprietary Specialty Drug Tool Box and provided an overview of each of the four components that lie inside in order to educate our readers on the process of managing this growing segment of the pharmacy benefit. Today, we'd like to place our focus on the first component, pricing, to provide a more in depth look at the first stage of managing pharmacy benefits. See below:

    Before figuring out which specialty pharmacies you will work with to dispense specialty drugs to patients, it's important to ask your PBM about any current discounts or rebates that apply to certain specialty drugs and also agree on a timeline, i.e quarterly for the PBM to provide new specialty drug updates and associated discounts. Since specialty drugs can be extremely expensive, you also want to discuss which drugs are similar, i.e treat similar disease states, and therefore should be preferred with a rebate.

    In order to find cost-effective solutions, it is also important to take a look at biosimilar or generic drugs that can be used in place of specialty drugs and consider at least identifying them in your 2015 plan design program so that they can be added when approved. Currently there are several generic versions of specialty drugs and it is important that your PBM Agreement applies the lowest MAC pricing to these generics. Many PBMs do not provide MAC pricing to specialty drug generics. When it comes to pricing, there are many other questions that you should ask your PBM. Some are as follows:
    • Does your PBM contract state different discounts for different limited distribution drugs?
    • Does your PBM provide a per prescription rebate, a per brand prescription rebate or 100% of the actual manufacturer rebate for specialty drugs?
    • Can your PBM provide an updated specialty drug list with current discounts of the new drugs launched?
    • Do you audit high cost specialty drugs for adjudication accuracy?
    Be sure to check back for our next blog, which will focus on the second component of our specialty drug tool box, channel management!

    At PBIRx, our mission is to create optimal health care outcomes while minimizing overall health care costs. For more information on how we can help, visit us at or contact us at (888) 797-2479 today!