Specialty Drug Tool Box by PBIRx

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

With prescription drug prices increasingly rapidly along with PBM profits, you may be starting to consider the options you have when it comes to managing your company's pharmacy benefits. If there is one thing we know for sure, it is that you should meet with an expert consultant and auditor like ourselves to discover if your current health care solution is working in your favor. Specifically when it comes to specialty drugs, our team has created a proprietary Specialty Drug Tool Box that is used to help with optimizing management of rising specialty drug costs; take a look at the components of it below.

Step 1: Price

In managing your pharmacy benefit plan, you must be aware of the specific discounts and rebates that are available for certain specialty drugs, including generics, biosimilars and limited distribution drugs. Some questions to consider at this stage are:

• Does your PBM contract state different discounts for different limited distribution drugs?
• Can your PBM provide an updated specialty drug list with current discounts of the new drugs launched?
• Does your PBM provide a per prescription rebate, a per brand prescription rebate or 100% of the actual manufacturer rebate for specialty drugs?
• Are you sharing in the lower cost provided to the PBM for drugs with Value Based Contracts providing discounts/rebates back to the PBM if there is NOT a positive healthcare outcome?
• Do you work with an expert that can identify when a PBM prefers a higher cost specialty drug over its significantly lower cost generic equivalent because the PBM receives rebates?

Prior to making any decisions about specialty drugs as they relate to your pharmacy benefit plan, you must know about the cost effective solutions that can be applied, the robust pipeline, price increases, new generics and biosimilars, new rebate opportunities, etc.

Step 2: Channel Management

Depending on your dispensing facility (for example, a retail pharmacy or doctor’s office), you may see a variation in the management services and rebates available to you. Before you make a decision on which you will choose, you need to look into the differences to determine a facility that has the most benefit to both the plan and your members. At PBIRx, we will work with you to analyze each of your options to find the one that best suits your needs.

Step 3: Clinical Review and Management

The third stage of our Specialty Tool Box has to do with utilizing proprietary clinical algorithms to discover programs that result in low-cost health care outcomes. At this point, we will take a closer look at your plan’s design to learn if there are other cost saving opportunities available to you, not just those that include a discount on certain drug costs. PBMs work very closely with drug manufacturers whose miscellaneous fees and rebates provide significant profit margins. Those profit margins incentivize formulary decisions and not necessarily the plan’s costs. PBIRx has no ties to a drug manufacturer and therefore, is independent of decisions based on rebates that are not shared with our clients.

Step 4: Clinical and Pharmacoeconomic Outcomes

Once your pharmacy benefit plan has been analyzed by PBIRx with new recommendations and associated savings/member disruption, if any, the next step is to confirm the management of patients’ disease states. Here, we help by going over all of the specialty drugs chosen for your plan and figuring out how patients and their diseases will ultimately be cared for and managed. Many PBIRx clients value our proprietory Specialty Drug Adherence programs, for which Compliance programs are implemented and member’s behavior changes,  along with associated savings is reported back.

To learn more about our Specialty Drug Tool Box and how we can apply the strategies within to assist with your pharmacy benefit plan in 2016, please give us a call at (888) 797-2479. Additional information about each of our individual services is also available on our website. 

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.

Pharmacy Benefit Costs As They Relate To Total Healthcare Costs

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

The idea that pharmacy costs are growing in number is no surprise to those who either -

1. Offer pharmacy benefits to their employees or members; or
2. Have a need to fill prescriptions and access other treatments and medications.

However, the time frame in which pharmacy spend increases is rather short, and the extent to which it is increasing is rather large.

According to EBN, Employee Benefit News, pharmacy benefit costs accounted for 16% or more of total healthcare budgets for 77% of employers in 2014. A high number at that, the number of employers who are spending a good portion of their total healthcare budgets on pharmacy benefits increased 6% from 2013. In fact, approximately 5% of employers confirmed that even more than 30% of their budgets went directly to pharmacy costs. While these numbers may seem low to some in the broader scheme of things, we understand and realize how quickly these changes could affect those who find themselves within the group who must determine how budgets are divided.

Why?

The real question now is - why? Why are pharmacy costs adding up now more than ever before? Although pharmaceutical services have always been known to be on the more expensive side, the need for providing entities to spend more is likely attributed to the recent rise in specialty drug costs. Electronic prescribing by doctors, the increase of telemedicine, expanding indications for current drugs and preventative medications at no copay are other contributors of increased drug utilization.

Are you responsible for offering pharmacy benefits to those in need? Are you concerned about the changing nature of their costs? Here at PBIRx, our goal is to give you more control over your healthcare costs, and are able to successfully achieve that goal by offering exceptional pharmacy benefit consulting and auditing services. For more information about how we can help you ensure that you are not spending more then necessary for any healthcare outcomes, 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!