Auditing PBM Agreements Can Save Money

PBIRx®
Intelligent Solutions in Pharmacy Benefits
12 Wheelers Farms Road, Milford, CT 06461
(888) 797-2479

“Pharmacy” benefit costs in the US are predicted to increase from $323 Billion in 2016 to $580-$610 Billion in 2021 according to a report by QuintilesIMS Holdings, Inc.    

Pharmacy Benefit Managers love when their clients do NOT audit their pharmacy benefit agreement!   This way the creative language in their contracts is not revealed and you pay more and more each month and each year.

Auditing pharmacy claims can generate significant monetary recoveries, while at the same time providing you with the confidence that your current pharmacy benefit financial discounts and guarantees are competitive for 2017.  PBIRx can tell you what parts of your PBM contract are not competitive. PBIRx clients experience a 5%–15% recovery of total drug spend, while at the same time ensuring that the PBM contract financial terms are being adjudicated correctly.

PBIRx®, a pharmacy benefit auditing and consulting corporation with locations in Connecticut and Missouri  since 1993, has the technology, tools, years of experience and experts that can help you recover lost dollars using our AuditRx® technology.   

PBIRx has several references nationwide that will attest to not only the audit recoveries that we facilitate, but also the savings to their pharmacy benefit budget.  Pharmacy Benefit Agreements, whether direct with the PBM, through the health plan carrier (i.e. Anthem, Cigna, Aetna, etc), or through a coalition, state that auditing may be limited to a certain time period (typically the previous 12 months).  Not knowing the period of time that you can audit your pharmacy benefit claims and not reaching out to PBIRx results in a lost recovery opportunity!

Why you should have PBIRx review your Pharmacy Benefit Agreement with no fee:

• To determine if there is a potential pharmacy benefit claims  recovery
• To know if the discounts in the PBM Agreement are actually being adjudicated as stated
• To learn if the financial model (discounts, rebates, guarantees, etc.) is 2017 competitive
• To provide union negotiated pharmacy benefits at a lower cost
• To know if there are other opportunities for savings to reduce costs while maintaining current copays and plan design features in negotiated union contracts
• To be reminded of important dates that could result in lost “time value of money”, i.e. guarantee/rebate remittance, agreement renewal period, non competitive automatic renewals, etc.

PBIRx will provide a courtesy review of your PBM agreement upon request.  Please contact David Sirowich at dsirowich@pbirx.com or call 203-882-1188 to discuss your potential savings in greater detail.  You can also visit our website www.pbirx.com for more information.

PBIRx has been exclusively providing intelligent solutions to clients in the management of pharmacy benefit costs since 1993. With a staff that includes IT personnel, actuaries, financial analysts, clinical pharmacists, attorneys, HIPAA Compliance Officers and many more experts, PBIRx’s mission is to create optimal health care outcomes while minimizing overall health care costs. For more information, please visit www.pbirx.com or call (888) 797-2479.

Glucose Meters and Test Strip Tips for Diabetes Patients

PBIRx®
Intelligent Solutions in Pharmacy Benefits
12 Wheelers Farms Road, Milford, CT 06461
(888) 797-2479

Follow instructions carefully. Glucose meters and test strips are sold with instructions for use. You can call the manufacturer of your device or your health care provider if you have questions.

Ask your health care provider to watch you test yourself to be sure you are using your device correctly.

Do quality control checks of your device. Regularly test your meter using a control solution to make sure the test strips and meter are working properly together.

Understand what the meter display means. Be sure you know how high and low glucose values are displayed on your meter. Sometimes they are displayed as “LO” or “HI” when the glucose level is beyond the range than the meter can measure. Talk to your health care provider if you have questions.

Know which test site gives the most accurate results. 

• Readings from alternate sites—such as your forearm or palm—can be less accurate than fingertip readings when your glucose levels change quickly (like after you eat or during exercise).
• Take a reading from a fingertip if you think your blood glucose is low, especially if results from an alternate test site don’t match how you feel.

Know when and how to clean and disinfect your glucose meter.  Always read and follow the directions in your manual.

Do not use pre-owned or second-hand test strips.

• Test strips should be properly stored to give accurate results. If you buy pre-owned strips, it is hard to know whether the strips were stored properly.
• Test strip vials that have been opened by another person may have small amounts of blood on them, which can put you at risk for infection.
• Pre-owned test strip vials may have been tampered with, which means that they may not be safe to use. (i.e., the expiration dates might have been changed or covered up.)
• Pre-owned strips also may not have been cleared by the FDA for sale in the United States.

Know when to report device problems. In an emergency, call 9-1-1. For non-emergencies, the FDA encourages you to report any issues to MedWatch, the FDA’s voluntary reporting program. (i.e., devices that don’t work, suspected incorrect results, or any other problem with your meter or test strips.)

PBIRx has been exclusively providing intelligent solutions to clients in the management of pharmacy benefit costs since 1993. With a staff that includes IT personnel, actuaries, financial analysts, clinical pharmacists, attorneys, HIPAA Compliance Officers and many more experts, PBIRx’s mission is to create optimal health care outcomes while minimizing overall health care costs. For more information, please visit www.pbirx.com or call (888) 797-2479.

New Rheumatoid Arthritis Drug

PBIRx®
Intelligent Solutions in Pharmacy Benefits
12 Wheelers Farms Road, Milford, CT 06461
(888) 797-2479

On May 22, 2017, the FDA approved a new drug, Kevzara (sarilumab), manufactured by Sanofi/Regeneron Pharmaceuticals, indicated to treat adults with moderate-to-severe rheumatoid arthritis who have had an inadequate response to one or more disease-modifying antirheumatic drugs.  The patient receives one injection every two weeks at a cost of approximately $39,000 per year.  

This new drug will come with a boxed warning that cautions it may predispose patients to bacterial, fungal, viral or other infections.  Before use, patients should be tested for latent tuberculosis. PBIRx will continue to keep our members informed of the latest drugs available as well as their possible side effects.   PBIRx has been exclusively providing intelligent solutions to clients in the management of pharmacy benefit costs since 1993. With a staff that includes IT personnel, actuaries, financial analysts, clinical pharmacists, attorneys, HIPAA Compliance Officers and many more experts, PBIRx’s mission is to create optimal health care outcomes while minimizing overall health care costs. For more information, please visit www.pbirx.com or call (888) 797-2479.

Diabetes Drug Safety Communication

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

PBIRx has been informed by the FDA Safety Information and Adverse Event Reporting of increased risk of leg and foot amputations with the use of canagliflozin brands (Invokana, Invokamet, Invokamet XR).  The FDA will be requiring new warnings including Boxed Warning to be added to the canagliflozin drug labels to describe the risk.

The FDA has the following recommendation:

"Patients taking canagliflozin should notify your health care professionals right away if you develop new pain or tenderness, sores or ulcers, or infections in your legs or feet.  Talk to your health care professional if you have questions or concerns.  Do not stop taking your diabetes medicine without first talking to your health care professional."

Please follow the link to the FDA article:

https://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm558605.htm

PBIRx has been exclusively providing intelligent solutions to clients in the management of pharmacy benefit costs since 1993. With a staff that includes IT personnel, actuaries, financial analysts, clinical pharmacists, attorneys, HIPAA Compliance Officers and many more experts, PBIRx’s mission is to create optimal health care outcomes while minimizing overall health care costs. For more information, please visit www.pbirx.com or call (888) 797-2479.

FDA Approves ALS Drug

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

On Friday, May 5th,  for the first time in 22 years, the FDA approved Radicava (edaravone) to treat patients with ALS, also known as Lou Gehrig’s disease.  The Centers for Disease Control and Prevention estimates that there are approximately 12,000 to 15,000 Americans who have this disease, which attacks and kills nerve cells that control voluntary muscles.  A year’s course of the medicine will cost about $145,000 before discounts.

Radicava is an intravenous infusion administered with an initial treatment cycle of daily dosing for 14 days followed by 14 days without drugs.  The treatment then follows with dosing on 10 of 14 days followed by another 14 days without drugs.    The efficacy for this treatment was proven in a six-month clinical trial in Japan.  At Week 24, individuals receiving the drug experienced less of a decline on a clinical assessment of their daily functioning than those who received the placebo -- the patient’s symptoms deteriorated more slowly.  

Radicava does have side effects.  The most common reactions are bruising, headaches and gait disturbance.  Other risks include hives, swelling, shortness of breath and allergic reactions to sodium bisulfate that may cause anaphylactic symptoms.

If you suffer from ALS, contact your doctor to find out if this new drug may benefit you.

For additional information:

https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm557102.htm?source=govdelivery&utm_medium=email&utm_source=govdelivery

https://www.forbes.com/sites/matthewherper/2017/05/05/fda-approves-first-new-drug-to-treat-als-in-22-years/#770a82f27fb3

PBIRx has been exclusively providing intelligent solutions to clients in the management of pharmacy benefit costs since 1993. With a staff that includes IT personnel, actuaries, financial analysts, clinical pharmacists, attorneys, HIPAA Compliance Officers and many more experts, PBIRx’s mission is to create optimal health care outcomes while minimizing overall health care costs. For more information, please visit www.pbirx.com or call (888) 797-2479.

EpiPen Voluntary Recall

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

On Friday, March 31, the FDA alerted consumers to the voluntary recall of 13 lots of Mylan's EpiPen and EpiPen Jr Auto-Injector products that are used for emergency treatment of severe allergic reactions.  The recalled products were distributed from December 2015 through July 2016.  These devices may contain a defective part that could result in its failure to activate. This recall impacts the 0.3mg and 0.15mg strengths.

For updates, lot numbers and additional information, go to: www.Mylan.com/EpiPenRecall. 

Consumers should keep and use their current EpiPen products, if needed, until they get a replacement.  If you have a recalled EpiPen product, contact Stericycle to provide a container to return the recalled medication.  You will also receive a voucher to redeem for a free replacement product.  Please contact Stericycle at 877-650-3494.

If you have any questions or concerns, contact Mylan Customer Relations at 800-796-9526 or at customerservice@mylan.com . 

PBIRx has notified all clients and brokers of this recall and will always be proactive to our consumers when we receive important pharmacy information that may impact their health.

PBIRx has been exclusively providing intelligent solutions to clients in the management of pharmacy benefit costs since 1993. With a staff that includes IT personnel, actuaries, financial analysts, clinical pharmacists, attorneys, HIPAA Compliance Officers and many more experts, PBIRx’s mission is to create optimal health care outcomes while minimizing overall health care costs. For more information, please visit www.pbirx.com or call (888) 797-2479.

Change is on the Horizon for the Affordable Care Act

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

President Trump and the Republican-led Congress plan to ‘repeal and replace’ the Affordable Care Act, also known as Obamacare with expected details to be revealed  by early to mid March.  Early leaks refer to changing or eliminating the individual mandate, income based subsidies, Planned Parenthood funding, current Medicaid funding and all the law’s taxes. The leaks also mention capping the employer sponsored insurance at the 90th percentile of current premiums and allowing states to determine mandatory or essential benefits. (http://www.politico.com/story/2017/02/house-republicans-obamacare-repeal-package-235343 )

In January, a budget resolution was passed that called for major changes to the law to be made in a subsequent bill.  President Trump signed an executive order (https://www.whitehouse.gov/the-press-office/2017/01/2/executive-order-minimizing-economic-burden-patient-protection-and) that calls for federal agencies to ‘waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the act’ that would ‘impose a fiscal burden’ on states, healthcare providers, individuals and others in the health industry.  The only response to this order has come from the IRS which has told tax preparers and software firms that it will not automatically reject tax returns that fail to state whether the tax filer had health insurance during the year.  The IRS noted that the rule change does not change the taxpayers’ responsibility to obtain health insurance and pay any penalty for noncompliance.  

In his first speech to Congress on February 28th, President Trump laid out five broad ideas that he wants the ACA replacement to address:

• Ensure that Americans with pre-existing conditions have access to coverage
• Provide tax credits and expanded Health Savings Accounts to buy health coverage
• Give State Governors resources and flexibility needed with Medicaid
• Implement legal reforms that protect patients and doctors from unnecessary costs that drive up the cost of insurance and work to bring down the artificially high price of drugs
• Give Americans freedom to purchase health insurance across state lines.

http://www.businessinsider.com/trump-state-of-the-union-speech-on-obamacare-repeal-replace-2017-2

At this point, it is believed that people who purchased insurance for 2017 should be covered for the remainder of the year.  The uncertainty, though, will come in 2018.  Some insurers are pulling out of the individual insurance market.  Humana has already announced it will not participate in the exchanges next year.  The CEO of Aetna has told reporters that they may pull out of Obamacare “market-by-market, based off of the level of competition and whether it can achieve an adequate return on capital”, but will decide after reviewing rates by mid May.  (http://www.cnbc.com/2014/02/06/aetna-may-pull-out-of-obamacare-ceo.html ) Insurers have been given an extension until the end of June to tell the federal government if they plan to participate in 2018.

Until a bill is passed, there is much unknown regarding the fate of the Affordable Care Act, and the future for an estimated 20 million people who are currently insured.

PBIRx has been exclusively providing intelligent solutions to clients in the management of pharmacy benefit costs since 1993. With a staff that includes IT personnel, actuaries, financial analysts, clinical pharmacists, attorneys, HIPAA Compliance Officers and many more experts, PBIRx’s mission is to create optimal health care outcomes while minimizing overall health care costs. For more information, please visit www.pbirx.com or call (888) 797-2479.