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: 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!

The Truth Behind Limited Distribution Speciality Drugs

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

In the pharmaceutical world, Specialty Drugs are a high cost commodity that are often overlooked. By definition, Specialty Drugs are prescription medications that require special handling, administration or monitoring. They are typically used to treat complex or chronic conditions and though they are necessary for the well-being of many, they are undoubtedly some of the most expensive medications currently available - well over $600 per Rx to $35,000 per Rx for a 30 day supply.

Drugs of this kind can be taken orally, injected or inhaled, and since they are prescribed in different doses, they require extensive management in more areas than just price. To assist in the management of specialty drugs, there is an 11 digit code included within their packaging that provides insight into its strength, name, and even its manufacturer.

Many high cost specialty drugs fall under the category of Limited Distribution Drugs (LDD). Limited distribution refers to the idea that only certain Specialty Pharmacies are approved to handle and distribute these drugs to patients. Manufacturers of LDD Specialty Drugs select one or more Specialty Pharmacy allowed to dispense the LDD. If a Pharmacy Benefit Manager's (PBM) Specialty Pharmacy was not selected to dispense such a drug, the PBM must facilitate the delivery of the drug through one of the drug manufacturer's selected LDD pharmacy(ies). The selected one or more Specialty Pharmacy provides many manufacturer required services including special provider/patient training on the dispensing, dosing, and side effects of the LDD drug. The pharmacy is also responsible for working with providers to be sure that they are aware of the Risk Evaluation Mitigation Strategy (REMS) documents that must be discussed with the patient and completed by both the provider and the patient. REMS documents can be up to 100 or more pages of information.

LDD Specialty Drugs are NOT assigned to the same discounts that are assigned to other Specialty Drugs. The pricing provides increased profits to all PBMs and must be evaluated and negotiated prior to signing a contract.

Typically, LDD Specialty Drugs are assigned significantly lower discounts, if any, costing the client more and increasing PBM profits. Also, the discounts vary depending on which LDD pharmacies are used by the PBM. Thus, a $10,000 drug like Tyvaso at an estimated AWP of $10,000 with NO discount could be Post AWP less 17% with another PBM. Medical brokers do not have clinical algorithms and do not lease MediSpan to quickly determine which PBIRx clients' LDD drug pricing is optimized because of proprietary algorithms used during the RFP process or renegotiation of financial terms after an audit. PBM contracts often address the pricing of LDD drugs in words versus numbers, i.e LDD drugs vary in pricing OR provide Specialty Drug pricing without the inclusion of LDD drugs and their discounts. PBM profitability is ensured through vague information on LDD pricing to prospective clients.

Sutent and Bosulif, oral cancer drugs ranging in price from $4,000 to $14,000 depending on the strength and dosing, will be moved to LDD as of November 1, 2014. For one PBIRx client, the current discount for Sutent is Pre AWP -17.7%. As an LDD drug, Sutent will price at Pre AWP -12% after November 1, 2014 or approximately $10,000 more annually for the $14,000 strength. The client will be subject to a higher cost, while both the client's PBM AND the LDD Specialty Pharmacy will benefit from increased profits. It is also very important to understand the meaning of "Pre" versus "Post" AWP in comparing discounts, especially with high cost Specialty Drugs.

With a robust Specialty Drug Pipeline it is predicted that many new very high cost drugs will be dispensed as LDD drugs, and with Specialty Drug spend climbing upwards to 40% of total pharmacy spend, it is an area where an expert, such as PBIRx, can make a huge difference to a client's bottom line. Currently there are over 600 LDD drugs with various National Drug Codes (NDC).

Watch for more blogs addressing the PBIRx Specialty Tool box, which addresses many other components of managing Specialty Drug costs beyond LDD drugs.

At PBIRx, we use advanced technology to create algorithms that allow us to manage and utilize information about high cost Specialty Drugs so that we can further educate our clients. It is our goal to provide customized solutions to our clients in the management of pharmacy benefit costs resulting in optimal heath care outcomes while minimizing overall health care costs.

For more information on how we can help, visit us online at www.pbirx.com or contact us at (888) 797-2479 today!