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!

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!