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.