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!

No comments:

Post a Comment