Friday, October 30, 2015

Hillary Clinton Seeks To Fix Prescription Drug Prices

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

Have you been keeping up with the current presidential hopefuls’ plans for the future? If you have not, one that we would like to call attention to is Hillary Clinton’s desire to lower prescription drug prices. With costs continuing to skyrocket, as was seen when Daraprim rose from $13.50 to $750 nearly overnight for one pill, it does not surprise us that prescription drug prices are on the minds of those seeking office.

According to a recent article from USA Today, Clinton’s plan is to have pharmaceutical companies place more of their focus on research, with the hopes that doing so would lead to more generic and imported drugs. As we all know, the production of generics is very important for those who require prescriptions being that they are much more cost effective than brand-name alternatives. This, the article explains, would permit Medicare to “negotiate lower drug costs and cap out-of-pocket expenses for individuals with chronic health problems.”

Diving deeper into her plan, Clinton would also like to see drug companies using our tax dollars to further research and develop new drugs rather than for advertising purposes that solely benefit the company themselves. Additionally, alongside the hope that more generics would make their way to the market, Clinton mentions that she would like to see a reduction in the amount of time that companies can “exclusively produce new treatments.”

However, with all that said, we would like to point out that Clinton’s plan primarily focuses on the member, rather than the entities responsible for providing pharmacy benefits. Should this plan ever take effect, it will be extremely important for entities to keep an eye on what they are paying for their pharmacy benefits, as there may still be a spike in the costs they must cover even if more attention is brought to rebates for government and drug manufacturers.

This is where the team at PBIRx comes in. As a pharmacy benefit consulting and auditing company that strives to aid providing entities with their pharmacy benefit plans, we always have their best interests in mind when it comes to health care costs. Between our financial analysts, clinical pharmacists, attorneys and other experts in the pharmacy benefit management industry, we help our clients evaluate their plans and can deliver and implement solutions that find them cost-saving opportunities where applicable.

To learn more about our pharmacy benefit consulting and auditing services, or for more information about our take on Clinton’s drug pricing plan when it comes to your pharmacy benefits, please give us a call at (888) 797-2479.

PBIRx Is LIVE On Social Media

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

When you need information about pharmacy benefit plans, drug costs, health care reform and other similar topics, you need PBIRx. As a pharmacy benefit consulting and auditing company that works with a number of clients on their pharmacy benefits, we have dedicated ourselves to becoming a leading source of information on all subjects pertaining to the pharmaceutical and health care industries. 

To share our knowledge and expertise with others, we are active on the following social media sites:

Last, but certainly not least, there is also our blog! From new FDA drug approvals to overviews on certain drug types and insider news, we have the details you need to stay up to date on the ever changing nature of our industry. And the best part is, you can subscribe to our blog via email so that you can be the first to know when we have published a new post. It's simple! Just enter your email address in the corresponding box on the right hand side of our blog's homepage.  

To learn more about the PBIRx team and how we can help you through our consulting and auditing services, please give us a call at 1 (888) RxPBIRx (797-2479). And don't forget to visit us on our website! We recently updated the layout and design, making it much more user friendly so that you can access everything you need with ease. 

340B Orphan Drug Exclusion Ruling By Federal Court

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

340B Orphan Drug Exclusion Ruling

As of October 14, 2015, 340B Covered Entities such as rural referral centers (RRC) and free standing cancer hospitals (CAN) that had “Opted In” to purchase Orphan Drugs will no longer be able to utilize 340B pricing for “any” drug for which there is at least one Orphan Drug designation per ruling by Rudolph Contreras, United States District Judge.

Though entities that “Opted In” agreed to track the use of each drug by indication and to maintain audible records, the ruling is in favor of The Pharmaceutical Research and Manufacturers of America (PhRMA), which claims that HRSA incorrectly interpreted the Orphan Drug exclusion to be used for indications other than the Orphan Drug indication as a 340B eligible drug.

Another option for 340B Covered Entities was to “Opt Out” of submitting any drugs that are considered Orphan Drugs because “they are unable or unwilling to track by indication."

What is interesting is the large number of existing drugs for which there IS at least one Orphan Drug designation that would be surprising to some such as Crestor, Humira, Enbrel, Prozac, Betaseron, Copaxone and others. One thought is that by seeking at least one Orphan Drug designation for an existing drug, manufacturers therefore would not have to provide a 340B pricing discount and at the same time increase the cost of the drug.

A recent PBIRx 340B Compliance Audit for a covered entity that had “Opted Out” of submitting for drugs that are considered Orphan Drugs uncovered a significant issue. The 340B Covered Entity was using two different Contract Pharmacies that were each using two different Contract Pharmacy Service Providers (CPSPs). CPSPs establish automated operating procedures for the contract pharmacy program.

PBIRx’s  340B Compliance Audit identified that one contract pharmacy had submitted for 92 prescriptions for Crestor, which has one Orphan Drug designation, while the second contract pharmacy was compliant and had no submissions for Crestor or any other drug for which there is an Orphan Drug designation. Therefore, one of the covered entities contract pharmacy was non compliant and as such, posed a big loss of 340B status risk for the covered entity as HRSA could view this as diversion. PBIRx is working diligently with the client on an immediate resolution to protect their very valuable 340B status.

To protect your 340B status, contact our experienced and knowledgeable team for your 340B HRSA Compliance Audit at (888) 797-2479. Through the use of our cutting edge technology, we can provide you with the most comprehensive evaluation report and provide the necessary solutions where needed.

Monday, October 26, 2015

Pharmacy Benefit Actuarial Services At PBIRx

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

If you are an entity that provides pharmacy benefits to its employees or members, then we know your primary concern is likely taking care of those who are currently still active in your place of work. But, if you also offer pharmacy benefits to employees who are retired, then it is important to be aware of the aid you may be eligible to receive from the government.

Pharmacy benefit actuarial services by PBIRx

The Retiree Drug Subsidy Program is an opportunity available through Medicare that allows providing entities to continue offering eligible retirees employer sponsored coverage similar to what they received as an active employee. According to the Centers for Medicare and Medicaid Services, "it is generally considered the easiest and most straightforward of the available options, and can often be implemented with little or no benefit design changes to current coverage." That means that those who qualify are likely to be able to receive the same pharmaceutical services they once did even though they are no longer in a position of employment.

To be eligible for the reimbursement (as of January 1, 2006, the government provides a 28% drug subsidy for qualified plans), the Pharmacy Benefit Plan must be equal to or better than the Medicare Part D plan. Furthermore, it is required that an evaluation is completed and signed by a certified actuary, and an application must be submitted to the RDS program 90 days before the plan becomes effective.

How We Help

Here at PBIRx, we have dedicated a division within our company, Pharmacy Benefit Actuarial Services (PBAS), which handles the entire application process for clients seeking the Retiree Drug Subsidy. We have a team of actuaries who possess the certifications needed that can guide you through each of the necessary steps in order to determine your eligibility and ultimately, to receive the subsidy if approved. Below is just some of what we will do to get started:
  • Provide a courtesy review of date including estimated subsidy amount and estimated PBAS services fee.
  • Determine if your plan is eligible.
  • Determine if a modification of the plan will make you eligible if you are not already eligible.
  • Communicate all employer paperwork deadlines required by the government.
  • Develop and participate in a communication strategy for your Medicare eligible employees.

To find out if you are eligible and move forward with the process, we encourage you to give us a call and set up an appointment for your FREE consultation!

For more information, please visit us at or contact us at (888) 797-2479.

Tuesday, October 20, 2015

Pharmaceutical Industry Acronyms Defined

Intelligent Solutions in Pharmacy Benefits
612 Wheelers Farms Road, Milford, CT 06461
(888) 797-2479
Pharmaceutical Industry Acronyms Defined
Have you ever tried to read a piece of literature, only to learn that you were unfamiliar with many of the terms within? Although you may have an idea of what you are reading, it can be difficult to fully grasp all concepts when you are unclear about terms and phrases that are used over and over again.

Specifically focusing on the pharmaceutical industry and the nature of our work, we at PBIRx realize how complex it can be for current clients, prospective clients and those simply seeking information about what we do to understand the texts they come across. With so many variations of different laws and guidelines, and a multitude of acronyms used to define benefit plans, treatments and more, there is so much that needs to be learned before one can become truly familiar with all that they see and read.

To help clear up any confusion, we have outlined a few of the most common acronyms our team uses along with their definitions:

CMS: CMS refers to the Centers for Medicare and Medicaid Services. To learn more about this government agency and its role in health care, click here.

CTIRx: This term is especially important for our clients to know! CTIRx (Clinical Technology Intelligence) is one of our own proprietary offerings with over 100 clinical algorithms used with our client’s actual utilization to identify programs resulting in significant savings. It is a division of PBIRx that works to recommend clinical cost savings opportunities and facilitate program implementations with doctors and members. We also measure the actual savings as compared to estimated savings provided to our clients.

HIPAA: HIPAA is an acronym for the Health Insurance Portability and Accountability Act of 1996. This act is voluminous and provides protection to American workers including:
  • Limited exclusions for medical conditions that already exist.
  • Offering new rights that permit individuals to receive health coverage in various situations, such as when they get married or lose previous coverage.
  • Prohibiting discrimination in terms of both enrollment and cost based on factors pertaining to health-status.
  • Major restrictions on the protection of Patient Health Information (PHI)
But that is not all! Learn more here.

OTC: OTC stands for over the counter, meaning you are not required to provide a prescription to buy the medicine. Some examples of over the counter medicines (or non prescription medicines) are Advil, Claritin and Tylenol. 

PMPM: PMPM is the acronym for per member per month. Typically looked at and determined on a monthly basis, this refers to the ratio of service or cost for the number of employees in a group.

If you are in charge of your company's benefits, these terms are extremely important to know as they will likely be mentioned in various conversations and within several documents that you receive. But should there be other terms that you are still unsure about, we want to define them for you right away! To have your questions answered, be sure to visit us on Facebook or Twitter to let us know what still needs to be clarified.

Here at PBIRx, we are dedicated to making sure that our clients are familiar with the information they are presented every step of the way. For more information about our services and how we can help you next with the management of your pharmacy benefit plan, please give us a call at (888) 797-2479.

Friday, October 16, 2015

Do You Know The Games That Your PBM Plays Behind YOUR Back?

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

Do you know the games that your PBM plays behind your back?
As an entity that provides pharmacy benefits to its employees or members, it is absolutely critical that you fully understand how your PBM operates after a deal has been made and your contract has been signed. Though you may feel confident that the terms and agreements proposed and negotiated will be upheld, it is not unusual for PBMs to fail to comply. Compliance failure can be due to several factors including lack of knowledge by not using pharmacy benefit consulting expertise, such as those provided by PBIRx, human error in setting up and modifying contractual details, system changes when PBMs merge or are acquired, etc. These compliance failures result in unnecessary increased costs as PBMs work to increase their own profitability.

Take the recent Novartis Kickback Scheme as an example. As reported in an article by the Wall Street Journal, allegations were made against Novartis for offering patient referrals to Accredo Health Group in exchange for encouraging refills of Exjade. Essentially, Novartis is claimed to have offered some type of financial benefit to the specialty pharmacy (which is run by Express Scripts) in order to boost sales of their products and therefore increase their profit.

Further explained in an article from BioPharmaDIVE, the arrangement between Novartis and Express Scripts is said to have lasted for four years (from 2008-2012) and caused Medicare, Medicaid and other similar programs to be "defrauded." Meaning, money was obtained illegally from these programs through the alleged deceiving actions of Novartis and the specialty pharmacy Accredo Health Group.

To put an end to the accusations, Express Scripts has officially agreed to pay $60 million dollars. But will will this be the last time a kickback scheme like this occurs?

Though unfortunate, it is important for all benefit providers to be aware of the possibility that their PBM is prioritizing the profits of the stockholders, versus lowering and managing the growing costs associated with the pharmacy benefit. That is why we place such an emphasis on auditing pharmacy benefit plans! By meeting with an expert team like PBIRx, entities can rest assured knowing that they are not falling victim to a scheme that is costing them more in the long run.

For more information about our pharmacy benefit auditing and consulting services, please visit or contact us at (888) 797-2479 today.

Monday, October 12, 2015

Biosimilars vs. Biologics - What's The Difference?

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

The difference between biosimilars and biologics
Though plan sponsors may be responsible for providing one or more types of benefits to employees or members, one of the most commonly misunderstood is the pharmacy benefit. Why? With so many categories of drugs out there, each with their own requirements and guidelines, there is a vast amount of information that must be processed to be fully aware of how and where costs are being distributed.

To breakdown drug categories a bit further and focus on a new class of high cost specialty drugs, we would like to focus on biologics and biosimilars, beginning with the BPCIA:

The Biologics Price Competition and Innovation Act (BPCIA) is a piece of the Affordable Care Act that states that a biological product can be considered a biosimilar if data suggests that it is already extremely similar to a previously approved originator biologic specialty drug. Essentially, it encourages the development of a biosimilar once the originator specialty biologic's (the drug that was originally approved) exclusivity ends (typically after 12 years). In current news, Presidential candidates are proposing to reduce the 12 year exclusivity to 7 years.

But what exactly is a biologic or a biosimilar? By definition, biologics are drugs that are derived from natural sources, such as humans, animals or microorganisms. They are designed to treat diseases and other medical conditions, but can be used to prevent disease dependent upon circumstances. When you think of biologics, think along the lines of vaccines, gene therapies and cellular therapies.

On the other hand, biosimilars are a type of biologic that are approved by the FDA because they are similar in nature to other already FDA approved biological products often referred to as the originator drug. However, it is important to note that some biosimilars may not be interchangeable with the originator drug depending on the type of FDA approval.

Where cost is concerned for biosimilars vs. biologics, biosimilars have been predicted to reduce drug spending by the billions over 10 years. Some of the most current biosimilars that have already launched and others that are expected to hit the market this year are:
  • Zarxio (for Neupogen)
  • Infliximab (for Remicade)
  • Epoetin Alfa (for Epogen)
Tying it all back to plan sponsors, they must be prepared to take advantage of cost savings by changing their plan designs to encourage Specialty Drug biosimilar utilization. Since some are infusible drugs, they need to either carve the originator drug from the medical to the pharmacy benefit for prior authorization and opportunity for biosimilar dispensing OR, put a trigger in place for medical approval to prefer the lower cost biosimilar.

For more information about biosimilars and biologics and how they affect a pharmacy benefit plan, connect with PBIRx today! We can analyze your plan to determine if it is designed in the most cost effective way and educate you further on the difference between each of the current drug categories. To speak with one of our consulting and auditing experts, please give us a call at (888) 797-2479 or email today.

Friday, October 9, 2015

The New PBIRx Website Is Now LIVE!

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

It has been an incredible summer for the team here at PBIRx! On May 1, we moved into our new office space within our current building. At the same time, we were also working on launching our new website! If you visit today, we are pleased to announce that you will be presented with a new and improved site that offers all of the information about us, our services and our industry that you need to know!

One of the features that we are most excited about is that our website exhibits a responsive design. That means that no matter which device users turn to when visiting (whether it be their cell phone, tablet or desktop), all of the data and information will be adjusted accordingly in order to adapt to the proper screen size. How easy is that? Now users can easily access the information they need without having to struggle with words and images that are cut off or distorted due to improper sizing.

In addition to our responsive design, we also made it a priority to incorporate features that benefit both current clients and prospective clients. Therefore, a client login tab has been added (where current clients can access their reports at any time) and the opportunity for prospective clients to speak with one of our specialists has been made even easier through our contact form. As it is our goal to always assist providing entities with solutions that will benefit them and their total healthcare spend, we of course wanted to include a place where they could easily get started with us!

If you haven't already, we encourage you to visit our new website today - and don't forget to let us know what you think! To leave your feedback, be sure to visit us on our Facebook, Twitter, LinkedIn or Google+ page!

Since 1993, PBIRx has been providing intelligent solutions to various clients regarding the management of pharmacy benefit costs. With a staff of IT personnel, actuaries, financial analysts, clinical pharmacists, HIPAA compliance officers and more, strategic plans are offered to all that include unbiased, objective financial analyses with sensitivity to both member and client. For more information, please call 1-888-RxPBIRx (797-2479).

Thursday, October 8, 2015

Americans Continue To Struggle With Prescription Drug Costs

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

Prescription Drug Costs

Once again prescription drug costs are making headlines as they continue to put a strain on our wallets. As reported recently by CNBC, approximately one third of Americans who rely on prescription medications are still struggling to keep up with price changes, and as a result, they're cutting back on their spending elsewhere. Though a $40.00 increase (on average) may not seem like much, it sure does add up quickly - especially for those who need more than one prescription.

In addition to cutting back on recreational activities or worse - cutting back on other things they need like groceries and food - CNBC explains that some patients are starting to view their prescriptions differently and "cut corners" with how they use them. And the result? Certainly a negative one on their health. In fact, the CNBC article details that Consumer Reports found that "24 percent of people who had seen higher drug prices in the past 12 months had skipped filling a prescription because of the cost."

Although health insurance changes have been made due to Obamacare, the out-of-pocket costs are what is doing it for patients. Brand-name, generic and specialty drugs have all seen a spike in price, and unfortunately, many of the common medications utilized are rising the most. "Medications that treat common conditions including asthma and high blood pressure were at the top of a list of drugs whose prices have risen in recent years," says CNBC. 

Since the need for prescription medication is certainly going to stick around, it is important for all providing entities to stay up to date with their pharmacy benefits to ensure that employees and members have the coverage they need to obtain what they need. If you're in charge of your entity's pharmacy benefits, give us a call at (888) 797-2479 or visit to learn how we can audit your plan for accuracy today!