Specialty Drug Tool Box Spotlight: Clinical and Pharmacoeconomic Outcomes

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

 

As a leader in pharmacy benefit management services, it is our goal to make sure that our clients fully understand the process we use to help them find the right solutions for their health care plan. In our most recent blogs, we focused on the first three components of the Specialty Drug Tool Box and today we will cover the fourth!

The final piece of our tool box rests in clinical and pharmacoeconomic outcomes. Ultimately, this stage encompasses all that came before it by taking a closer look at the specialty drugs chosen and focusing on how both the patient and the disease will also be cared for and managed.

Now that your plan is in place and your patients are provided with the medicine they need, it is crucial to make sure you are managing the patient's disease state as they begin to take the medication as prescribed. To be specific, this includes looking at coordination of care, medication adherence, side effect management and finally, disease management. 

At PBIRx, we are currently piloting integration of specialty pharmacy and medical data using proprietary algorithms to provide actionable data. As you finalize the management of your pharmacy benefits with your PBM, we recommend asking about the different types of programs and reports that are available in order to demonstrate management of the disease in addition to just dispensing a specialty drug.

By closely following the steps outlined in our proprietary Specialty Drug Tool Box, we believe that our clients will have found a solution that best fits their pharmacy benefit needs. Interested in experiencing it for yourself? If you're an entity that provides pharmacy benefits to your employees or members, we suggest connecting with one of our consultants today to enjoy all that our management services have to offer using cutting edge technology and proprietary algorithms. For more information, visit us on our website or contact us at (888) 797-2479 today!

Specialty Drug Tool Box Spotlight: Clinical Review and Management

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

As we move forward with our proprietary Specialty Drug Tool Box, we come to the third stage known as clinical review and management. Now that you have decided which specialty drugs you will include in your pharmacy benefit plan, have agreed on competitive and auditable discounts, analyzed and chosen appropriate dispensing channel options for various high cost specialty drugs, it is time to look at your plan from a clinical perspective. You must be certain that the specialty pharmacy chosen has optimal, detailed, current and updated clinical criteria; a well established formulary; and a robust utilization management program for all high cost specialty drugs.

This stage focuses on your plan's benefit design and looks at various clinical analyses and their ability to produce higher savings than just a discount on the cost. As you search for the best solutions, keep in mind that the co-pays for preferred, non preferred and biosimilar/generic drugs should always coincide with the analyses on efficacy, drug costs and rebates. Additionally, due to the sometimes toxic side effects, complex dosing and cost of specialty drugs, it is also imperative that the disease itself is managed, in addition to managing the drug that is prescribed to effect a positive and optimal cost health care outcome.

As you work with your PBM to decide which solutions will be the most effective for your budget and the population of people you plan to provide benefits for, consider the following:

1. Has your PBM worked with you to model and report different clinical programs and interventions and the associated savings? 
2. Has your PBM shared their specialty drug prior authorization criteria to be certain that it is detailed, evidence based, robust and current?

If you feel like these topics have not been covered, we recommend asking your PBM to dig deeper into their analysis so that you can be sure you have found the best solution for your pharmacy benefit plan.

Do you need help managing the growing high costs of specialty drugs in your pharmacy benefit? Contact PBIRx today! Our mission is to create optimal health care outcomes while minimizing overall health care costs. For more information, visit us at www.pbirx.com or give us a call at (888) 797-2479 today!

Specialty Drug Tool Box Spotlight: Dispensing Channel Management

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

 

Following along with our Specialty Drug Tool Box, the next category we focus on is that of dispensing channel management. In order to effectively manage high cost specialty drugs as part of your pharmacy benefits, you must first research and analyze all of the available dispensing channel options before making a decision on which option you will direct members to for each specialty drug. Since specialty drugs are only available for purchase at pre-determined specialty pharmacies or licensed distributors, you will have to decide which is the best for you to partner with based on not only, the array of discounts available, but also the clinical prior authorization protocol to be sure the drug is appropriate for the medical indication AND that the specialty pharmacy is managing the utilization to prevent wastage resulting in a positive healthcare outcome.

There are several options to consider in regards to the dispensing of specialty drugs. The following is a list of a few channels that are available to provide you with the service you need:

• Retail pharmacy
• PBM owned specialty pharmacy
• Doctor's office
• In house hospital pharmacy
• Infusion center
• Limited distribution approved pharmacy
• Niche specialty pharmacy that offers high touch patient services at similar discounts to the PBM owned specialty pharmacy

At PBIRx, we suggest looking into each of these options in great detail since drug discounts, member management services and rebates vary based on the specific dispensing facility. Additionally, be aware that your PBM may only promote their own specialty pharmacy even when there are pros and cons to other dispensing options. That is why PBIRx suggests asking your PBM about the opportunities listed above, since they might satisfy your needs better than the pharmacy your PBM promotes.

In order to find the right solutions for our clients, using proprietary algorithms, PBIRx diligently analyzes and audits all of the available dispensing options for high cost specialty drugs as part of our efforts to help you manage your pharmacy benefits. For more information on how we can help, visit us at www.pbirx.com or contact us at (888) 797-2479 today!

Specialty Drug Tool Box Spotlight: Pricing

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

 

Here at PBIRx, we believe that it is crucial for our clients to fully understand the nature of pharmacy benefits and how to approach their cost and other associated health care outcomes. In our previous blog, we highlighted our proprietary Specialty Drug Tool Box and provided an overview of each of the four components that lie inside in order to educate our readers on the process of managing this growing segment of the pharmacy benefit. Today, we'd like to place our focus on the first component, pricing, to provide a more in depth look at the first stage of managing pharmacy benefits. See below:

Before figuring out which specialty pharmacies you will work with to dispense specialty drugs to patients, it's important to ask your PBM about any current discounts or rebates that apply to certain specialty drugs and also agree on a timeline, i.e quarterly for the PBM to provide new specialty drug updates and associated discounts. Since specialty drugs can be extremely expensive, you also want to discuss which drugs are similar, i.e treat similar disease states, and therefore should be preferred with a rebate.

In order to find cost-effective solutions, it is also important to take a look at biosimilar or generic drugs that can be used in place of specialty drugs and consider at least identifying them in your 2015 plan design program so that they can be added when approved. Currently there are several generic versions of specialty drugs and it is important that your PBM Agreement applies the lowest MAC pricing to these generics. Many PBMs do not provide MAC pricing to specialty drug generics. When it comes to pricing, there are many other questions that you should ask your PBM. Some are as follows:

• Does your PBM contract state different discounts for different limited distribution drugs?
• Does your PBM provide a per prescription rebate, a per brand prescription rebate or 100% of the actual manufacturer rebate for specialty drugs?
• Can your PBM provide an updated specialty drug list with current discounts of the new drugs launched?
• Do you audit high cost specialty drugs for adjudication accuracy?

Be sure to check back for our next blog, which will focus on the second component of our specialty drug tool box, channel management!

At PBIRx, our mission is to create optimal health care outcomes while minimizing overall health care costs. For more information on how we can help, visit us at www.pbirx.com or contact us at (888) 797-2479 today!

PBIRx's Proprietary Specialty Drug Tool Box

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

 

As experts in the pharmaceutical field, PBIRx thrives on providing the best pharmacy benefit solutions to any entity that offers benefits to its employees or members.The demand for high cost oral and injectable specialty drugs continues to rise with existing drugs getting FDA approval for new indications, which dramatically increases utilization. Between increased utilization, new specialty drugs launched and manufacturers increasing prices several times a year, specialty drugs are now representing up to 40% or more of the total pharmacy benefit spend.

Management of not only the cost of the specialty drug, but also effecting a positive and lowest cost healthcare outcome requires many components beyond just the actual specialty drug discount provided by the PBM. That is why at PBIRx, we have developed a proprietary Specialty Drug Tool Box that is used with every client to manage the growing segment of the pharmacy benefit.

The following provides some insight on our Specialty Drug Tool Box with various components to consider in optimizing management of rising specialty drug costs:

1. Price: First and foremost, it is important to know and understand about specific discounts and rebates that are available for various specialty drugs including generics, biosimilars and limited distribution drugs.

2. Channel Management: Drug discounts, member management services and rebates vary based on the specific dispensing facility i.e retail pharmacy, PBM owned specialty pharmacy, doctor's office, in house hospital pharmacy, infusion center and approved limited distribution specialty pharmacy.

3. Clinical Review and Management: Significant savings can be achieved beyond the drug discount by using various clinical algorithms to identify and implement programs resulting in overall low cost positive healthcare outcomes.

4. Clinical and Pharmacoeconomic Outcomes: Lastly, once a plan is in place it's time to make sure you are managing the patient's disease state to include coordination of care, medication adherence and disease management.

For more information on our Specialty Drug Tool Box or how PBIRx can help you manage your pharmacy benefits, visit us at www.pbirx.com or contact us at (888) 797-2479 today!

Getting to Know PBIRx®!

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

As an entity that provides benefits to its employees or members, it's important to make sure that your plan covers several medical categories to ensure optimal health care coverage. In today's medical field, the demand for high cost specialty drugs and prescription medications specifically is continuing to rise. Managed Care Plans, Hospitals, Employer Groups, Unions and Third Party Administrators are eager to work with companies that can help them to reduce and optimize their growing pharmacy spend. In fact, today, pharmacy costs represent approximately 40% of total health care costs!

Since pharmacy costs make up a significant portion of health care costs, many entities recognize the importance of offering pharmacy benefits to their employees or members. However, as the costs of specialty drugs continue to rise, so do the costs of the pharmacy benefits that may be included in your plan.

This is where we come in! At PBIRx, our experienced, diverse and educated team of consultants will work with you to reduce your pharmacy benefit costs without sacrificing any health care outcomes or opportunities. To assist you with your pharmacy benefit plans, we offer the following services here at PBIRx:

• Pharmacy Benefit Consulting
• Pharmacy Benefit Auditing (AuditRx®)
• Pharmacy Benefit Actuarial Services, including Clinical Technology Intelligence and Dynamic Clinical Integration
• Third Party 340B HRSA Compliance Audits
• First Fill Optimization

In each of these services, we work closely with our clients to provide customized solutions that help reduce and control pharmacy costs in their health plans. Using robust technology, along with a staff that includes actuaries, financial analysts, clinical pharmacists, attorneys, HIPAA Compliance Officers and other experts in the pharmacy benefit management industry, we evaluate your current pharmacy benefit plan and devise a strategic plan that reduces overall costs while maintaining the benefits your employees/members currently receive, resulting in positive and lower costing healthcare outcomes.

For more information on how we can help, visit us at www.pbirx.com or give us a call at (888) 797-2479. Also, be sure to LIKE us on Facebook and FOLLOW us on Twitter to stay up to date with the latest news in the pharmaceutical industry and pharmacy benefit cost savings opportunities.