Pharmacy Benefit Auditing at PBIRx

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

 

Since pharmacy costs represent nearly 40% of today's total health care costs, it is crucial for any entity that provides pharmacy benefits to its employees or members to audit all the financial discounts and guarantees stated in their PBM contract to be sure that claims are being adjudicated exactly as you agreed to in your PBM negotiations. 

Furthermore, as the cost and utilization of specialty drugs continues to rise, it is even more important to make sure that the discounts negotiated are in accordance with the terms outlined in the signed contract including Limited Distribution Specialty Drugs and new drugs that come to market. 

At PBIRx, it is our goal to make sure that the language, discounts and guarantees stated in our clients' contracts are being adjudicated accurately by the PBM, which is why we provide comprehensive pharmacy claims audits using our proprietary AuditRx® platform.

AuditRx® presents our clients with a comprehensive written report with Exhibits to provide to the PBM. Additionally, our team of experienced actuaries and financial analysts have been very successful in negotiations with various PBMs resulting in significant monetary recoveries.

The following is a brief description of the AuditRx® process, which can be annually, quarterly or monthly:

• Facilitate delivery of all PBM claims data in an electronic format to PBIRx.
• Format financial terms which are stated in the signed contract between the client and the PBM, into the AuditRx® platform.
• Provide auditing results in both summary and detailed formats on the accuracy of information such as contracted brand/generic discounts, dispensing fees for retail, mail and specialty pharmacy along with administrative fees.
• Review contract language related to PBM shared savings billing reconciliation and member co-payments in accordance with plan design and claims paid by ineligible members.
• Provide eligibility audit to be sure that claims are not being adjudicated for members no longer eligible for pharmacy benefits.

For more information on the AuditRx® program, visit us on our website or contact us at (888) 797-2479 today!

Health Plan Identifier Requirements

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

 

The Department of Health and Human Services (HHS) requires all health plans to obtain a ten-digit "unique identifier" from a government sponsored agency. Plans must use a Health Plan Identifier (HPID) to identify a health plan in standard Health Insurance Portability & Accountability Act (HIPPA) electronic transactions.

Plans that are fully insured on the medical and self-funded on their pharmacy benefit are required to apply for an HPID.

Key compliance dates to obtain the HPID are as follows:

• Health plans, with the exception of small health plans, must obtain HPIDs by November 5, 2014.
• Small health plans (annual receipts of $5 million or less) must obtain HPIDs by November 5, 2015.
• All plans that generate electronic transactions are required to use the identifier in those transactions beginning November 7, 2016.

The online application is available through the Health Plan and Other Entity Enumeration System (HPOES) housed within CMS' Health Insurance Oversight System (HIOS) and may be accessed through the CMS Enterprise Portal. Users will need to provide additional information to register in the enterprise portal and obtain a user ID and password.

The application also requests a Payer ID or National Association of Insurance Commissioners (NAIC) number. CMS has advised that self-funded employers who do not have these numbers may enter "not applicable" in this field on the application.

To learn more about the application process, you may view CMS' HPID and OEID overview presentation by clicking here. In addition, videos are available to walk through each step of the application process to obtain a HPID for a controlling health plan, a sub health plan and other entity identifier. See Quick Reference Guide to: Obtaining a Controlling Health Plan HPID.

For more information, please contact PBIRx at (888) 797-2479 today!

Hydrocodone Classification Change

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

 

For safety reasons, the U.S. Drug Enforcement Administration (DEA) has reclassified medications containing hydrocodone to a Schedule CII narcotic. In the past, medications that contained hydrocodone were considered controlled substances, but the classification was not as high. Effective October 6, the new classification means that a doctor can no longer include refills for these medications on prescriptions.

So why is the DEA making this change? These changes are designed to minimize the misuse of these medications, while still making sure that patients with severe pain have reasonable access to the medications they need.

And what does this mean for you? The following are a few important things to consider as of October 6, 2014:

• Any remaining refills on current hydrocodone products will no longer be valid. You will need to see your doctor each time you need a refill for a written prescription. 
• Your doctor will NOT be allowed to call in or fax hydrocodone prescriptions.
• In some states, nurses or physician assistants will no longer be able to prescribe hydrocodone medications.

Maxor sent out letters explaining this change to members who have had these meds filled at mail order within the last 90 days.

Please note, however, that there may be some member disruption. Most pharmacists and doctors are aware of the new classification of hydrocodone and will be prepared for the change. As noted in the communication from Maxor, there has been ample notification of the impending change.

This is an excellent class of drugs for treating pain; however, it is a highly abused drug class that is often diverted from its intended purposes and used for drug abuse. That is why we view it as a positive change to reduce unwarranted abuse of this class of drugs.

For more information, please contact PBIRx at (888) 797-2479!

Meet The PBIRx Team: Robert Kademian

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

 

At PBIRx, we have an outstanding team of actuaries, financial analysts, clinical pharmacists, attorneys, HIPPA Compliance Officers and experts in the pharmacy benefit management industry who, all together, help create optimal health care outcomes while minimizing overall health care costs for our clients. It is because of them that we are able to be a leading consultant in the Pharmacy Benefit industry, and therefore, we'd like for you to get to know them a bit better!

Today, we'd like to introduce you to our Director of Strategic Accounts, Robert C. Kademian! Check out his PBIRx interview below:

1. What is your full name and title at PBIRx?  Robert C. Kademian, Director, Strategic Accounts.
2. How long have you been working with PBIRx? 6 years 
3. What do your day to day responsibilities include? Client services – plan design, clinical recommendations, resolving member or client issues, member communications, and account reviews to show clients how their plan is doing. Involved in developing cost saving strategies for clients using the expertise and talent offered throughout PBIRx. I communicate options to clients, and help craft communication from clients to plan members.  I am also a member of the clinical team and take part in some sales meetings. 
4. When did you first decide you wanted to work in the pharmaceutical industry? What about it interests you? I was always interested in how medicines worked as a child, and the roles of doctors, nurses and pharmacists.  I was so interested that I became a pharmacist, then worked for drug companies for over two decades. 
5. What school did you attend and what did you get your degree in? B.S. in Pharmacy, with a focus on business from the Mass. College of Pharmacy and Allied Health. MBA with a focus on marketing from Boston College. 
6. What has been your greatest achievement at work thus far?  Not really one that stands out. It is most likely how we now present and implement the clinical component of a client’s initial clinical plan. We are now able to move new clients from where they are when we start, to where they need to be, and do it as fast or slow as they want. I think it gives new clients a better picture of what we will be doing for them early in the relationship, which makes them feel more comfortable about having chosen to work with PBIRx.
   
   Note from PBIRx President: an integral part of  the PBIRx Clinical Department, Bob has enhanced our Clinical Program options resulting in thousands of dollars of savings for PBIRx clients. He has also been a leader for the staff being certified in Population Health Management providing additional information to everyone based on his years of experience.  Lastly, Bob has been instrumental in nurturing a team culture at PBIRx.
   
7. Outside of work, what do you do for fun?  Family time and playing soccer are the first things that come to mind.  I also run, play tennis, and workout at the gym.  I also enjoy learning about business and business leaders – what great businesses have in common,  business principles, and biographies of business leaders.

Big thank you to Robert for all of his hard work and dedication to PBIRx. We are so fortunate to have you on our team!

For more information on PBIRx, visit us on our website or contact us at (888) 797-2479.

PPACA Requirements and MOOP As They Relate To Health Coverage

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

 

Beginning with the plan year that starts on or after January 1, 2015, the Affordable Care Act (ACA) states that all non-grandfathered group plans are required to accumulate out-of-pocket expenses for Essential Health Benefits (EHB) across several benefit providers. For 2015, the Maximum-Out-of-Pocket (MOOP) is expected to be as follows:

$13,200 for families

$6,600 for individuals

The Affordable Care Act, or Patient Protection and Affordable Care Act (PPACA), also mandates that certain preventive items and services must be covered at 100% within a patient's health plan. This means that such preventive items and services are to be excluded from deductibles or other cost-sharing limitations and covered with no member cost. Coverage is required one year after the U.S Preventive Services Task Force (USPSTF) has issued the new recommendation on the first plan year that starts after such one year date. The plan may use reasonable limits on the frequency, but not the dollar amount of preventive care that it will cover.

Recently, Breast Cancer preventives and Preeclampsia prevention have been added to the list of services that are required to be available without falling subject to cost-sharing limitations. Please see below for some insight into each of these two preventive services:

Breast Cancer Prevention:
For those candidates who are at increased risk for breast cancer and at low risk for adverse medication effects, the USPSTF suggests that clinicians should prescribe risk reducing medications such as tamoxifen or raloxifen. Coverage is required on the first plan year effective date after September 24, 2014.

Preeclampsia Prevention:
By definition, preeclampsia is a complication that occurs during pregnancy that is characterized by high blood pressure and signs of damage to other organ system such as the kidneys. To prevent preeclampsia in high risk women, the USPSTF recommends the use of low-dose aspirin (81 mg/d) after 12 weeks of gestation. Coverage is required on the first plan year effective date after 2015.

For a more comprehensive list of preventive services that are covered without cost-sharing or to learn more about the PPACA requirements that will affect non-grandfathered health plans starting next year, contact us at (888) 797-2479 today! At PBIRx, our consultants can provide you with a more detailed analysis about the items and services that are included under the Affordable Care Act and can educate you further on how to effectively manage your maximum-out-of-pocket costs through different plan options.

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!