Change is on the Horizon for the Affordable Care Act

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

President Trump and the Republican-led Congress plan to ‘repeal and replace’ the Affordable Care Act, also known as Obamacare with expected details to be revealed  by early to mid March.  Early leaks refer to changing or eliminating the individual mandate, income based subsidies, Planned Parenthood funding, current Medicaid funding and all the law’s taxes. The leaks also mention capping the employer sponsored insurance at the 90th percentile of current premiums and allowing states to determine mandatory or essential benefits. (http://www.politico.com/story/2017/02/house-republicans-obamacare-repeal-package-235343 )

In January, a budget resolution was passed that called for major changes to the law to be made in a subsequent bill.  President Trump signed an executive order (https://www.whitehouse.gov/the-press-office/2017/01/2/executive-order-minimizing-economic-burden-patient-protection-and) that calls for federal agencies to ‘waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the act’ that would ‘impose a fiscal burden’ on states, healthcare providers, individuals and others in the health industry.  The only response to this order has come from the IRS which has told tax preparers and software firms that it will not automatically reject tax returns that fail to state whether the tax filer had health insurance during the year.  The IRS noted that the rule change does not change the taxpayers’ responsibility to obtain health insurance and pay any penalty for noncompliance.  

In his first speech to Congress on February 28th, President Trump laid out five broad ideas that he wants the ACA replacement to address:

• Ensure that Americans with pre-existing conditions have access to coverage
• Provide tax credits and expanded Health Savings Accounts to buy health coverage
• Give State Governors resources and flexibility needed with Medicaid
• Implement legal reforms that protect patients and doctors from unnecessary costs that drive up the cost of insurance and work to bring down the artificially high price of drugs
• Give Americans freedom to purchase health insurance across state lines.

http://www.businessinsider.com/trump-state-of-the-union-speech-on-obamacare-repeal-replace-2017-2

At this point, it is believed that people who purchased insurance for 2017 should be covered for the remainder of the year.  The uncertainty, though, will come in 2018.  Some insurers are pulling out of the individual insurance market.  Humana has already announced it will not participate in the exchanges next year.  The CEO of Aetna has told reporters that they may pull out of Obamacare “market-by-market, based off of the level of competition and whether it can achieve an adequate return on capital”, but will decide after reviewing rates by mid May.  (http://www.cnbc.com/2014/02/06/aetna-may-pull-out-of-obamacare-ceo.html ) Insurers have been given an extension until the end of June to tell the federal government if they plan to participate in 2018.

Until a bill is passed, there is much unknown regarding the fate of the Affordable Care Act, and the future for an estimated 20 million people who are currently insured.

PBIRx has been exclusively providing intelligent solutions to clients in the management of pharmacy benefit costs since 1993. With a staff that includes IT personnel, actuaries, financial analysts, clinical pharmacists, attorneys, HIPAA Compliance Officers and many more experts, PBIRx’s mission is to create optimal health care outcomes while minimizing overall health care costs. For more information, please visit www.pbirx.com or call (888) 797-2479.

Biosimilars vs. Biologics - What's The Difference?

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

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 info@pbirx.com today.

PBIRx's Role in Healthcare Reform Compliance

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

The topic of Healthcare Reform, otherwise known as The Patient Protection and Affordable Care Act (PPACA), the Affordable Care Act (ACA) or even "Obamacare," is one that requires a lot of attention in the pharmacy and pharmacy benefit industry. Being that the first version of the law reads "The Patient Protection and Affordable Care Act," one may assume that this law has adjusted healthcare plans to be more affordable today than in the past. However, the nature of the law suggests that the desired level of affordability is still not where many hoped it would be.

A particular section of the Affordable Care Act that we would like to point out is Coverage of Preventive Services. There are specific terms and guidelines stated by the US Preventative Services Task Force (USPSTF), as to what preventive services must be covered under a patient's health plan and some of those services also include the coverage of certain pharmaceutical drugs at a zero copayment.

This is where PBIRx steps in! At PBIRx, one of our responsibilities related to the Affordable Care Act is to make sure that all of our clients are compliant with the USPSTF coverage of certain drugs for plans that are non-grandfathered. Thus, we carefully review our clients' current plan design of covered drugs and make sure that they accurately reflect the guidelines stated in the ACA and that such guidelines have been implemented appropriately with their PBM and communicated to our clients' members. But our services don't stop there! As we work towards making sure everyone is compliant with the law, we also make sure our clients have the necessary documentation such as a Summary of Benefits and Coverage available to their members.

The following is a list of preventative drugs often subject to certain criteria, which may include age and/or disease state, for which the USPSTF mandates a zero copay:

• Aspirin to prevent cardiovascular disease for certain ages
• Fluoride Supplements
• Folic Acid
• Iron Supplements
• Vitamin D
• Immunizations
• Oral Contraceptives
• Breast Cancer Preventive (plan renewals starting 10/1/14)
• Aspirin for preeclampsia risk (plan renewals starting 9/1/15)

Furthermore, it is important to note that smoking cessation coverage is also included in the list of preventative drugs that the USPSTF mandates a zero copay for. However, since this coverage does not have a deadline, anyone that currently requests drugs or services to aid in this process at a $0 copay is given a "safe harbor" compliance status.

For more information on how PBIRx works to help with ACA compliance, please give us a call at (888) 797-2479 today!