Auditing PBM Agreements Can Save Money

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

“Pharmacy” benefit costs in the US are predicted to increase from $323 Billion in 2016 to $580-$610 Billion in 2021 according to a report by QuintilesIMS Holdings, Inc.    

Pharmacy Benefit Managers love when their clients do NOT audit their pharmacy benefit agreement!   This way the creative language in their contracts is not revealed and you pay more and more each month and each year.

Auditing pharmacy claims can generate significant monetary recoveries, while at the same time providing you with the confidence that your current pharmacy benefit financial discounts and guarantees are competitive for 2017.  PBIRx can tell you what parts of your PBM contract are not competitive. PBIRx clients experience a 5%–15% recovery of total drug spend, while at the same time ensuring that the PBM contract financial terms are being adjudicated correctly.

PBIRx®, a pharmacy benefit auditing and consulting corporation with locations in Connecticut and Missouri  since 1993, has the technology, tools, years of experience and experts that can help you recover lost dollars using our AuditRx® technology.   

PBIRx has several references nationwide that will attest to not only the audit recoveries that we facilitate, but also the savings to their pharmacy benefit budget.  Pharmacy Benefit Agreements, whether direct with the PBM, through the health plan carrier (i.e. Anthem, Cigna, Aetna, etc), or through a coalition, state that auditing may be limited to a certain time period (typically the previous 12 months).  Not knowing the period of time that you can audit your pharmacy benefit claims and not reaching out to PBIRx results in a lost recovery opportunity!

Why you should have PBIRx review your Pharmacy Benefit Agreement with no fee:

• To determine if there is a potential pharmacy benefit claims  recovery
• To know if the discounts in the PBM Agreement are actually being adjudicated as stated
• To learn if the financial model (discounts, rebates, guarantees, etc.) is 2017 competitive
• To provide union negotiated pharmacy benefits at a lower cost
• To know if there are other opportunities for savings to reduce costs while maintaining current copays and plan design features in negotiated union contracts
• To be reminded of important dates that could result in lost “time value of money”, i.e. guarantee/rebate remittance, agreement renewal period, non competitive automatic renewals, etc.

PBIRx will provide a courtesy review of your PBM agreement upon request.  Please contact David Sirowich at dsirowich@pbirx.com or call 203-882-1188 to discuss your potential savings in greater detail.  You can also visit our website www.pbirx.com for more information.

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.

Understanding the Fine Print in PBM Proposals and Agreements

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

By now it is common knowledge that drug prices are rising in nearly every category. In 2015, branded drug costs increased by 14.77%, specialty drug costs increased by 9.21%, and generic drug costs increased by 2.93% when compared to the previous year (as reported by Employee Benefit News). With that said, many have looked to try and control these costs, and earlier this month, Express Scripts, a PBM, announced that they are working to develop more strategies that result in employers being able to offer drug benefits in a more affordable way.

Specialty drugs, drugs that are used to treat more complex disease states such as cancer, are said to have an extremely high inflation rate - about 10% - 20% each year. With this in mind, Express Scripts developed what they refer to as their Inflation Protection Program. As of January 1, 2016, Express Scripts is now offering a program, which sounds too good to be true, to “shield participating plans from the full cost impact of year-over-year price increases on brand drugs.” This program only addresses high cost “brand” drugs for which PBMs negotiate significant rebates and for which there are often lower cost “generic” drugs and “over the counter” alternatives. However, it is in the fine print where the unveiling of the ambiguity lies.

Too good to be true?

To employers who offer pharmacy benefits to their employees or members, knowing that Express Scripts is willing to cover the cost of services when inflation goes above an agreed upon threshold can result in a heavy sigh of relief. However, it is “understanding” the fine print, not only in the proposal, but more importantly in its entirely in the actual PBM Agreement. For example, how is your plan’s inflation cap determined and what must YOU do in order to ensure that Express Scripts will continue to uphold their side of the deal?

If something sounds too good to be true, listen to your gut. This is why you need to work with PBIRx, which is independent of the PBM. That means we always put our clients’ best interests first and not the PBM’s profitability. As a pharmacy benefit auditing and consulting firm for over 25 years, PBIRx is a master and expert at understanding, interpreting and negotiating PBM Agreements and adjunct agreed upon calculation methodology language so that our clients come out the winner. Together we challenge PBM Agreement language that sounds too good to be true!

For more information about our pharmacy benefit consulting and auditing services, please visit www.pbirx.com or call (888) 797-2479 today.