Monday, March 30, 2015

An Overview Of Orphan Drugs

Intelligent Solutions in Pharmacy Benefits
612 Wheelers Farms Road, Milford, CT 06461
(888) 797-2479
PBIRx's overview of orphan drugs
Generic drugs, brand name drugs, biosimilars, orphan drugs - with so many drug categories out there, it can be difficult to keep up with the definitions of all the categories of drugs and the recent trends involved. If you frequent our blog often, you may already be familiar with terms such as generic drugs and biosimilars because we have talked about them before. But on another note, orphan drugs may be something you are still unsure about and if you are a payer, remember that orphan drugs are often subject to Limited Distribution Pharmacy discounts, which are significantly lower than your other specialty drug discounts. Be sure to get a copy of your most current Specialty Drug list and associated discounts to INCLUDE Limited Distribution drugs and see for yourself. 

Today, we put together an overview of this drug category specifically to educate you! See below for a few facts about the industry, the drugs, and recent trends; but first, the definition:

Orphan drugs are pharmaceuticals that have been designed to treat a rare disease or condition. Through the Orphan Drug Act (ODA), drugs or biological products can be given this status so long as they meet criteria as outlined by the ODA and FDA.

Facts and Trends:
  • In 2014, orphan drugs cost patients approximately $137,782 per year. At the same time, non orphan drugs came in at a price of $20,875, on average.
  • By 2020, it is expected that orphan drugs will make up about 19% of prescription drug sales (not including generic drugs).
  • Phase III orphan drug development costs are half of non orphan development drugs. However, the amount of time it takes to develop such orphan drugs is not shorter than non orphan drugs.
  • As a result of the cancer drug Opdivo, Bristol-Myers Squibb is predicted to surpass Novartis as the leader in orphan drug sales in the year 2020.
For more information about orphan drug trends, please click here.

As one of Connecticut's leading pharmacy benefit auditing and consulting firms, we have made it our business to learn everything there is to know about orphan drugs and how your pharmacy benefit spend may be impacted by them. To learn how we can help you get more control over your healthcare costs, especially at a time where they are so high as demonstrated in the above list, please visit us at or contact us at (888) 797-2479 today.

Friday, March 27, 2015

Pharmacy Benefit Costs As They Relate To Total Healthcare Costs

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

The idea that pharmacy costs are growing in number is no surprise to those who either -
  1. Offer pharmacy benefits to their employees or members; or
  2. Have a need to fill prescriptions and access other treatments and medications.
However, the time frame in which pharmacy spend increases is rather short, and the extent to which it is increasing is rather large.

According to EBN, Employee Benefit News, pharmacy benefit costs accounted for 16% or more of total healthcare budgets for 77% of employers in 2014. A high number at that, the number of employers who are spending a good portion of their total healthcare budgets on pharmacy benefits increased 6% from 2013. In fact, approximately 5% of employers confirmed that even more than 30% of their budgets went directly to pharmacy costs. While these numbers may seem low to some in the broader scheme of things, we understand and realize how quickly these changes could affect those who find themselves within the group who must determine how budgets are divided.


The real question now is - why? Why are pharmacy costs adding up now more than ever before? Although pharmaceutical services have always been known to be on the more expensive side, the need for providing entities to spend more is likely attributed to the recent rise in specialty drug costs. Electronic prescribing by doctors, the increase of telemedicine, expanding indications for current drugs and preventative medications at no copay are other contributors of increased drug utilization.

Are you responsible for offering pharmacy benefits to those in need? Are you concerned about the changing nature of their costs? Here at PBIRx, our goal is to give you more control over your healthcare costs, and are able to successfully achieve that goal by offering exceptional pharmacy benefit consulting and auditing services. For more information about how we can help you ensure that you are not spending more then necessary for any healthcare outcomes, visit us at or contact us at (888) 797-2479 today.

Friday, March 13, 2015

PBIRx's Approach To Managing Pharmacy Benefit Costs

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

Managing pharmacy benefit costs in Connecticut
In a time where the cost of prescription medications and pharmaceutical services continues to rise, there is a pressing need for them to be controlled. Did you know that records from 2014 suggest that for more than half of today's employers (77% to be exact), pharmacy benefit costs made up 16% or more of their total healthcare budgets? And although 16% might not seem like such a significant number to some right now, the reality is that the total percentage of healthcare costs dedicated to pharmacy benefits is only going to continue to grow as the cost of services continues to rise.
As one of Connecticut's top pharmacy benefit consulting firms, our goal is to provide entities with cost saving solutions that allow them to offer desired healthcare services at the lowest possible costs. To do so, we have created a proprietary tool known as our Specialty Drug Toolbox. The following is a brief look into each stage of this valuable tool that we use with each and every one of our clients:
1. Price: To determine whether or not you are paying a fair price for your pharmacy benefit plan, we consider the specific discounts and rebates that are available for generic drugs, biosimilars and limited distribution drugs. This way, we can figure out whether or not your plan offers medications and services at the right price.
2. Channel Management:  Once we are familiar with the discounts and rebates you are entitled to, the next thing we look at is the various channels that can offer them. Since rebates vary based on certain dispensing facilities, we narrow down which ones work best for your plan.
3. Clinical Review and Management: Next, we focus on your plan from a clinical perspective. That means we analyze how your plan is designed and compare it to clinical data to determine if any additional savings are available for positive healthcare outcomes.
4. Clinical and Pharmacoeconomic Outcomes: Finally, the last stage of our analysis includes studying how you are/should be managing patient disease states. This part of our approach ultimately looks at how both the patient and the disease will be cared for as the patient starts to use the services they are entitled to through your pharmacy benefit plan.
Now that you are more familiar with our approach and how we can work with you to control your pharmacy benefit costs, it's time to get started. For more information on our proprietary Specialty Drug Toolbox and how it can benefit you through our pharmacy benefit consulting and auditing services, contact us at (888) 797-2479 today.

Thursday, March 12, 2015

340B Audits By PBIRx

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

As outlined by the U.S. Department of Health and Human Services, 340B Drug Pricing Programs require drug manufacturers to provide outpatient drugs at discounted prices to those organizations and entities that are entitled to them. In order to take advantage of this opportunity, such groups must be registered and enrolled in the program and must be compliant with all of the programs requirements. However, here at PBIRx, we understand that it can be easy to stray from program requirements and in turn, fail to be compliant with certain policies and procedures.

Our 340B Compliance Audits

Since failure to be compliant with the 340B Drug Pricing Program can cause a providing entity to lose their 340B status, we offer a third party 340B compliance audit service to ensure that your organization is operating based on the rules and regulations of the program. Performed on site, our audits can alert entities of any red flags that can trigger the loss of their 340B status. First, we will take a look at your policies, procedures and processes pertaining to 340B medications, then we will verify what you have in place to prevent non-qualified patients from receiving covered drugs and to prevent drugs from being subjected to duplicate discounts. Lastly, we will take a look at any transactions that directly relate to 340B medications and see where any discrepancies lie.

Although HRSA performs 340B compliance audits themselves, we at PBIRx can offer an in-depth report to help you ensure that your status remains as is. To learn more about our 340B audits as well as the rest of our pharmacy benefit auditing services, please visit us at or contact us at (888) 797-2479 today. 

Friday, March 6, 2015

Breast Cancer Preventive Medication Requirements

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

PBIRx, Milford CT, Breast Cancer Preventive Medcations
Did you know? For plan or policy years that began on or after September 24, 2014, preventive medications for breast cancer are required to be available at a $0.00 copay to women who display a high risk for the disease. However, mandated by the U.S Preventive Services Task Force (USPSTF), this requirement only applies to non-grandfathered group health plans. Do you fall within this category?

Being that these services can come at an extremely high cost otherwise, it is important for benefit providers to be aware of the changes to ensure that they have been put into effect appropriately where applicable. If they have not been and your employees or members are eligible to receive these services without cost sharing limitations, it is crucial for you to connect with an experienced team that can oversee their implementation.

Our Role

Here at PBIRx, we will work closely with your PBM to ensure that your plan covers the recommended medications - tamoxifen and raloxifene - for women who have a high risk of developing breast cancer. For those who do not have a high risk, copays will be required at the time of service.

For more information about the latest USPSTF mandates as they relate to your pharmacy benefit plan, please give us a call at (888) 797-2479 today.