Biologics: An Overview

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

By definition, biologics are medical products that are made from natural sources such as a microorganism, a human or an animal. Unlike other drugs that are made through a chemical process, biologics are manufactured in a living system and are usually very large molecules or mixtures of molecules that can not easily be identified. 

Just like other pharmaceutical drugs, biologics are used for the purpose of treating a medical condition or disease. Since biologics have proven to be an adequate solution for the treatment and prevention of some medical conditions, it is expected that over the next decade, the global biologics market will grow tremendously. In fact, at this rate, it is anticipated that by 2018, about 45 of the top 100 drugs will be biologics, pulling in about 50% of sales for that group of drugs.

When discussing biologics, it is also important to touch on their relationship with biosimilars and analyze how the growth of biologics will impact the production and growth of biosimilars as well. First and foremost, a biosimilar is any biological product that is very similar in nature and composition to an already licensed biological product. However, since biologics are extremely complex, it appears that it will be much more difficult for manufacturers to make a biosimilar version of originator biologics. Furthermore, in order to truly understand the safety and effectiveness of such biosimilars, manufacturers will need to carry out clinical trials where these drugs are tested. As a result, one can expect that biosimilar sales may not grow at the same rate as biologics since the process of integrating them into the market will be a much slower one.

At PBIRx, we are always following the latest pharmacy trends to better understand how the industry is changing. In turn, we are able to better analyze our clients' pharmacy benefit plans and develop solutions that are more in tune with the latest industry breakthroughs. For more information on biologics or to find out how we can help you with your pharmacy benefit plan, please visit us on our website or contact us at (888) 797-2479 today.

Generic Drug Costs Continue To Rise

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

Although most conversations about healthcare revolve around the plans for it to be more affordable and accessible to those who need it regardless of their financial situation, the fact of the matter is that drug costs are still placing a strain on many of our wallets. Specifically focusing on generic drugs, which are typically a patient's "go to" drug in order to reduce their pharmacy costs, recent trends suggest that their costs have actually gone in a different direction - the wrong direction.

According to ABC News, the prices of more than 1,200 generic drugs increased at an average of 448% in just one year. Albuterol Sulfate, a medication to treat asthma, is just one example of a drug that has skyrocketed in price. As stated in the article, between October of 2013 and April of 2014, the cost of two tablets of albuterol sulfate increased from just $11 to $434.

So what's being done to control the costs, you ask? Last month, the New York Times reported that lawmakers met to discuss the options currently available to provide relief from the astronomical increase in prices. One solution that was focused on was the possibility of having some prescription drugs imported to the United States from other countries. That is because recent findings suggest that many brand name equivalents of generic drugs are significantly cheaper in other countries. Although the importation of drugs is typically frowned upon, some states, such as Maine, passed a law allowing residents to order prescriptions from certain licensed pharmacies in Canada, Britain, Australia and New Zealand. The drugs delivered to people by an international pharmacy come directly from the manufacturer in flat blister packs.

At this congressional hearing, Vermont Senator Sanders and Maryland Representative Cummings also proposed another solution which suggested that generic drug manufacturers be mandated to provide a rebate to Medicare and Medicaid if their prices increased at a rate faster than typical inflation. However, interestingly enough, the generic drug maker representatives invited to attend opted out, providing no support or explanation for the recent rise in costs.

For more information on the current rise in costs and how it is to be handled, be sure to follow us on Facebook and Twitter. As soon as we know something, you'll know something!

At PBIRx, our goal is to provide you with more control over your healthcare costs so that you're paying the lowest price possible for the pharmaceutical services you need. As the end of the year approaches, we recommend having your pharmacy benefit plan audited to determine if you're receiving the discounts and rebates you deserve as stated in your contract. For more information on how we can help, please give us a call at (888) 797-2479 today!

Pharmaceutical Terms Defined: Part 2

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

In a recent blog, we defined five terms commonly used by members of our team in order to help you better understand our industry. Although those five terms will make reading pharmaceutical literature and understanding hot topics easier on your part, alone, they simply aren't enough. That is why today, we would like to introduce you to an additional five terms and their definitions! See below:

Prior Authorization (PA): The approval process/clinical criteria required in order to obtain particular drugs or certain amounts of others. Criteria is typically based on FDA manufacturer approved guidelines. As more expensive drugs are launched, this clinical criteria is expanding significantly, especially with Hepatitis C drugs.

Quantity Limit (QL): The quantity of medication that is recommended by the pharmaceutical manufacturer to be dispensed to a patient over a certain period of time at a particular copayment, coinsurance or deductible.

Rx: Symbol or acronym meaning "medical prescription."

Usual and Customary Price (U&C): The price that a pharmacy charges when there is no health insurance or other coverage for the purchase of prescriptions. This price varies from pharmacy to pharmacy on any given day.

Wholesale Acquisition Cost (WAC): The list price of a drug paid by a wholesaler, distributor or other direct account, before any rebates, discounts, allowances or other price concessions are offered by the supplier of such drugs.

Have you come across industry terms that you are still unsure about? Visit us on our Facebook or Twitter page and let us know! We would be pleased to provide you with the definition so you can better understand additional information on the topic you are seeking.

Since 1993, we have exclusively provided intelligent solutions to our clients in order to help them effectively manage their pharmacy benefit costs. Due to the combined effort of our actuaries, financial analysts, clinical pharmacists, attorneys, HIPAA Compliance Officers and other industry experts, we have found great success in finding our clients the rebates and discounts they deserve through their pharmacy benefit plans. For more information on how we can help, please visit us on our website or contact us at (888) 797-2479 today!

PBIRx's Role in Healthcare Reform Compliance

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

The topic of Healthcare Reform, otherwise known as The Patient Protection and Affordable Care Act (PPACA), the Affordable Care Act (ACA) or even "Obamacare," is one that requires a lot of attention in the pharmacy and pharmacy benefit industry. Being that the first version of the law reads "The Patient Protection and Affordable Care Act," one may assume that this law has adjusted healthcare plans to be more affordable today than in the past. However, the nature of the law suggests that the desired level of affordability is still not where many hoped it would be.

A particular section of the Affordable Care Act that we would like to point out is Coverage of Preventive Services. There are specific terms and guidelines stated by the US Preventative Services Task Force (USPSTF), as to what preventive services must be covered under a patient's health plan and some of those services also include the coverage of certain pharmaceutical drugs at a zero copayment.

This is where PBIRx steps in! At PBIRx, one of our responsibilities related to the Affordable Care Act is to make sure that all of our clients are compliant with the USPSTF coverage of certain drugs for plans that are non-grandfathered. Thus, we carefully review our clients' current plan design of covered drugs and make sure that they accurately reflect the guidelines stated in the ACA and that such guidelines have been implemented appropriately with their PBM and communicated to our clients' members. But our services don't stop there! As we work towards making sure everyone is compliant with the law, we also make sure our clients have the necessary documentation such as a Summary of Benefits and Coverage available to their members.

The following is a list of preventative drugs often subject to certain criteria, which may include age and/or disease state, for which the USPSTF mandates a zero copay:

• Aspirin to prevent cardiovascular disease for certain ages
• Fluoride Supplements
• Folic Acid
• Iron Supplements
• Vitamin D
• Immunizations
• Oral Contraceptives
• Breast Cancer Preventive (plan renewals starting 10/1/14)
• Aspirin for preeclampsia risk (plan renewals starting 9/1/15)

Furthermore, it is important to note that smoking cessation coverage is also included in the list of preventative drugs that the USPSTF mandates a zero copay for. However, since this coverage does not have a deadline, anyone that currently requests drugs or services to aid in this process at a $0 copay is given a "safe harbor" compliance status.

For more information on how PBIRx works to help with ACA compliance, please give us a call at (888) 797-2479 today!

Pharmaceutical Terms Defined

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

 

In order to understand topics covered in the pharmaceutical industry, it is first important to understand the terms and acronyms that are used to detail them. Since the terms used by industry experts can be quite complex and highly specific, it is often difficult to decipher their meaning at first glance. However, not understanding such terms makes it much more difficult to fully grasp industry news as well as information pertaining to your healthcare and pharmacy benefit plans.

To help you better understand our industry, we've put together a list of five terms commonly used by our team along with their definitions; check them out below!

Average Wholesale Price (AWP): Average wholesale price for a drug that is determined by the manufacturer and applied to each NDC code. The AWP does not necessarily reflect what pharmacies pay for a drug, but it is generally accepted as a pricing measure.

Generic Effective Rate (GER): The rate calculated by looking at the AWP of a generic drug as well as all generic drug claims submitted for a specific plan.

Maximum Allowable Cost Price (MAC): When brand drugs have more than one generic equivalent, prices will differ among each depending on manufacturer and package size. The MAC for such drugs is determined and implemented by your Pharmacy Benefit Manager. Some brands also have a MAC applied i.e brand with two distributors.

National Drug Code (NDC): The code every FDA approved drug is assigned, which could be 10 to 11 digits. The first 4-5 digits represent the Labeler Code (manufacturer, repacker or distributor), the next 3-4 digits represent the Product Code (strength, dosage form and formulation), and the last 1-2 indicate the Package Code (package forms and sizes).

Patient Protection and Affordable Care Act (PPACA): Also known as Obamacare and the Affordable Care Act, PPACA is a federal regulation that was signed into law by President Obama on March 23, 2010, with several amendments to date.

Though these are just a few of the most popular pharmaceutical terms, they are a great place to start to increase your knowledge and understanding of this industry. Stay tuned for our next blog which will contain an additional five!

At PBIRx, it is our goal to make sure our clients are fully educated on their pharmacy benefit plans, which is why we take the time to explain what it all means, every step of the way. With us, there is no confusion or uncertainty when it comes to your healthcare costs. To learn more about how we can help, please visit us on our website or contact us at (888) 797-2479.