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.

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