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!

340B Audits At PBIRx

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

 

Established in 1992 by the U.S Federal Government, the 340B Drug Discount Program requires drug manufacturers to provide discounts on outpatient drugs to eligible health care organizations or covered entities. According to the Health Resources & Services Agreement, HRSA, the 340B program enables such covered entities to stretch Federal resources as far as possible, given their ability to reach more eligible patients and provide more in depth services.

In 2012, however, congressional scrutiny of the 340B program oversight inspired the HRSA to conduct audits of 340B eligible entities. To remain in line with the program's purpose, it became their goal to prevent the diversion of covered drugs to non-qualified patients and they hope to prevent drugs from being subject to duplicate discounts under both the 340B program and the Medicaid rebate program.

To carry out their audits, HRSA targets certain entities based on their DSH status, 340B purchasing volume and the use of contract pharmacy arrangements. To date there have been over 200 HRSA audits initiated, and there is a current audit rate of approximately 6-8 entities per month.

Since obtaining a 340B status is critical to obtain certain drugs at such discounted prices, we at PBIRx want to make sure that our clients retain their status and not lose it. That is why we perform on site independent third party 340B compliance audits!

Our audits are a replica of the HRSA audits and are performed by a PBIRx audit team including pharmacists, analysts and experts in HRSA pharmacy policy. At the conclusion of their audit, we provide clients with a detailed evaluation report to help them prepare for their actual HRSA audit. Within our reports, we inform clients of which areas may compromise their participation in the 340B program and will help devise a solution to prevent it from happening. PBIRx has also provided additional support resulting in increased revenue from missed 340B opportunities.

Take action today and maintain your 340B status. For more information about our audits, visit us at www.pbirx.com or contact us at (888) 797-2479.

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!

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.

Save Money - It's That Easy

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

PBIRx would like to share exciting news with you, for your plan and for your members! Nexium 24HR OTC is NOW available on shelves. Nexium 24HR OTC is the same as the prescription version of Nexium 20mg, only at a fraction of the cost.

Nexium 24HR (OTC) will cost approximately $21 for a 28 day supply.

Nexium 20 mg prescription version costs the plan $250-$300 for a 28 day supply.

PBIRX Recommendations: 

You can save your plan 90% on this medication!

If your plan does not already exclude Nexium or cover the OTC versions, we can help you implement a change and start savings for your plan.

Our clinical team recommends that our clients exclude all brand prescription medications in this class and cover only the generic prescription versions (which are also around $300 per month) at Tier 2 and cover the OTC versions of these medications at Tier 1 or even at $0 copay.

Please contact your account manager if this is a change that you would like to implement for your plan.