Specialty Drug Tool Box by PBIRx

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

With prescription drug prices increasingly rapidly along with PBM profits, you may be starting to consider the options you have when it comes to managing your company's pharmacy benefits. If there is one thing we know for sure, it is that you should meet with an expert consultant and auditor like ourselves to discover if your current health care solution is working in your favor. Specifically when it comes to specialty drugs, our team has created a proprietary Specialty Drug Tool Box that is used to help with optimizing management of rising specialty drug costs; take a look at the components of it below.

Step 1: Price

In managing your pharmacy benefit plan, you must be aware of the specific discounts and rebates that are available for certain specialty drugs, including generics, biosimilars and limited distribution drugs. Some questions to consider at this stage are:

• Does your PBM contract state different discounts for different limited distribution drugs?
• Can your PBM provide an updated specialty drug list with current discounts of the new drugs launched?
• Does your PBM provide a per prescription rebate, a per brand prescription rebate or 100% of the actual manufacturer rebate for specialty drugs?
• Are you sharing in the lower cost provided to the PBM for drugs with Value Based Contracts providing discounts/rebates back to the PBM if there is NOT a positive healthcare outcome?
• Do you work with an expert that can identify when a PBM prefers a higher cost specialty drug over its significantly lower cost generic equivalent because the PBM receives rebates?

Prior to making any decisions about specialty drugs as they relate to your pharmacy benefit plan, you must know about the cost effective solutions that can be applied, the robust pipeline, price increases, new generics and biosimilars, new rebate opportunities, etc.

Step 2: Channel Management

Depending on your dispensing facility (for example, a retail pharmacy or doctor’s office), you may see a variation in the management services and rebates available to you. Before you make a decision on which you will choose, you need to look into the differences to determine a facility that has the most benefit to both the plan and your members. At PBIRx, we will work with you to analyze each of your options to find the one that best suits your needs.

Step 3: Clinical Review and Management

The third stage of our Specialty Tool Box has to do with utilizing proprietary clinical algorithms to discover programs that result in low-cost health care outcomes. At this point, we will take a closer look at your plan’s design to learn if there are other cost saving opportunities available to you, not just those that include a discount on certain drug costs. PBMs work very closely with drug manufacturers whose miscellaneous fees and rebates provide significant profit margins. Those profit margins incentivize formulary decisions and not necessarily the plan’s costs. PBIRx has no ties to a drug manufacturer and therefore, is independent of decisions based on rebates that are not shared with our clients.

Step 4: Clinical and Pharmacoeconomic Outcomes

Once your pharmacy benefit plan has been analyzed by PBIRx with new recommendations and associated savings/member disruption, if any, the next step is to confirm the management of patients’ disease states. Here, we help by going over all of the specialty drugs chosen for your plan and figuring out how patients and their diseases will ultimately be cared for and managed. Many PBIRx clients value our proprietory Specialty Drug Adherence programs, for which Compliance programs are implemented and member’s behavior changes,  along with associated savings is reported back.

To learn more about our Specialty Drug Tool Box and how we can apply the strategies within to assist with your pharmacy benefit plan in 2016, please give us a call at (888) 797-2479. Additional information about each of our individual services is also available on our website. 

The Causes of Rising Prescription Costs

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

You certainly do not need to be a patient that relies on a prescription or a professional in the pharmaceutical industry to know that the cost of prescription drugs is still on the rise. But considering that this is a reality we all face, the real question here is why - why is the cost of drugs still not showing any sign of slowing down? Although there are various factors that go into the cost of a drug, there are a few possible reasons that can be directly pinpointed to explain this trend; we have outlined three of them below:

1. Lack of control: While other countries are very particular about the way drugs are priced, the United States government does not have a policy when it comes to the regulation of drug prices. Ultimately, drugs are given their value based on what other drugs cost after they are compared to one another, not by what the government says they should be priced at.
2. Scarce competition: The more competition, the more likely it is to see a drop in prescription drug costs. However, competition is something that is often lacking when it comes to new drug treatments. As a result, those very few companies who produce a valuable drug tend to offer them at an extremely high cost - it is not until more hit the market that you can potentially expect to see a slight decrease.
3. Cost of research: The process of developing and seeking approval for a new drug is incredibly costly for drug manufacturers. Therefore, it is only natural that they first enter the market with a price that seems over the top. As the cost of manufacturing new drugs continues to rise, it is only natural to see a rise in the cost of the final product too.

While we may not be able to escape the fact that the cost of prescription drugs is continuing to skyrocket, one thing providing entities can do is have their pharmacy benefit audited to ensure that all contract language accurately reflects the actual claims adjudication, including the discounts, dispensing fees, rebates and guarantees stated in your current Agreement. Auditing your pharmacy benefit by an expert like PBIRx can also provide you with the information to know if your current financial model is competitive or how much money you are leaving on the table of the PBM.

If you have yet to meet with an expert team about your pharmacy benefit contract, start by calling PBIRx at (888) 797-2479. Through our comprehensive approach, you can start to get more control over your health care costs at a time when it matters most.

PBM’s Earnings Lead To Higher Health Care Costs and Harm Patients

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

You are likely already aware that health care costs are continuing to rise, which naturally makes it more difficult for patients to receive the services they require. However, did you know that the actions and ultimately the earnings that PBMs take and make are two of the primary reasons for this? In fact, an article from the Wilson County News reports that “in 2012, the CEO of the nation’s largest pharmacy benefit manager, Express Scripts, earned about $1 million every week.” With an income so great on a weekly basis, let alone what individuals of this status earn every month and so on, it seems only fair to question where it all comes from.

A main reason that PBMs can achieve such high earnings is due to the fact that they refuse to pay for medications that patients require - the less they cover, the more money they keep in their pocket by preferring drug alternatives for which the PBM has negotiated significant rebates and fees that are NOT shared with the client. As they continue to deny coverage for certain drugs and services (here is a list of some drugs that PBMs CVS/Caremark and Express Scripts will be excluding in 2016), they also make it more expensive for patients to receive what they need. In turn, health care costs continue to rise across the board and, in some cases, patients get sicker when the out-of-pocket costs become too much to cover.

Though they are an important part of our health care system, you must realize that PBMs will go to great lengths for their own benefit, including the fact that they will keep rebates for themselves rather than pass them along to the rightful pharmacy or insurance provider - another reason their earnings are so high. As a result, we cannot stress enough how important it is for providing entities to have their pharmacy benefit contracts audited to ensure that the financial components of the Agreement are competitive today and that the PBM is complying with the terms within. At PBIRx, our number one priority is to keep our client’s PBM Agreement financial model continuously reviewed and negotiated so that they can enjoy the added savings versus the PBM increasing their profits.

Remember that PBMs renegotiate with their pharmacy network every year and benefit from new pricing. Clients however, negotiate their PBM Agreement once every 2-5 years and at year two or three it is the PBM that has benefited from any new pricing, not the Client.

If you suspect that your PBM is holding back rebates that you are entitled to, or if you simply want to have your contract audited to ensure that your plan is being carried out correctly, do not hesitate to give us a call at (888) 797-2479. 

For more information about our services and how YOU can take control over your health care costs, please visit us on our website today.

Government Targets Prescription Drug Costs

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

With prescription drug costs consistently proving to be a hot topic within our industry, it is no surprise to us that government officials are beginning to get involved with the regulation of prices. In recent news, Democrats in the House of Representatives have suggested an “Affordable Drug Pricing Task Force,” which is meant to help fight and push back against the constant skyrocketing costs.

According to an article from the International Business Times, the United States is guilty of spending approximately $1,000 per person on prescription drugs. Not to mention, our cost of brand-name drugs comes out to be about twice as high as those in countries like the U.K where the government is more heavily involved with the negotiation of such prices. Considering that the ongoing rise of our drug costs is seemingly making it more difficult for patients to receive the care they need, it seems only right that the government is making an attempt to intervene.

Two particular problems that the U.S House of Representatives would like to see improvement on are:

1. That there is no transparency in our country's drug prices.
2. That the federal government does not have enough power when it comes to negotiating these prices.

However, one good thing that we can say for certain is that there is a bill in the hands of the Senate’s Finance Committee, which, if passed, would “grant the U.S Secretary of Health and Human Services the authority to negotiate with drug companies,” as reported by the International Business Times.

While there is no clear evidence that a task force such as the one proposed will actually lead to a decrease in drug prices, it is important to realize that government leaders are taking action - if you are following Presidential candidates, you may also already know that Hillary Clinton has her eyes set on reducing drug costs for Americans (more information here). Furthermore, Senator Bernie Sanders has also announced that he is investigating the rising cost of generic drugs. 

As a company whose primary goal is to find and explore cost saving solutions for clients with pharmacy benefits, we are always up-to-date with the latest news regarding the fight against rising drug costs. To stay up-to-date with us, be sure to connect with PBIRx on social media or give us a call at (888) 797-2479.

The Future of 340B in 2016

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

Considering that policies and procedures are ever-changing within our industry, it is crucial that experts like those at PBIRx have staff dedicated to industry changes bringing opportunities to their clients on a continuum. Continuing to place our focus on the 340B Drug Pricing Program, the latest news and updates suggest that 2016 is going to be quite a year, with changes and new initiatives on the way. Below, we want to share a few key points that we have compiled through our research on predictions about 340B for this year:

1. In September of 2016, it is expected that HRSA will publish their final 340B Program “mega-guidance.” For those of you who are unaware, their first “mega-guidance” was published in August of 2015, however, concerns and a federal court decision led to the need for a second edition.
2. New rules regarding monetary penalties for drug manufacturers that overcharge covered entities under the 340B program, such as hospitals, will be put into place. These rules are expected to be brought into the public eye in May of 2016.
3. Also in May of 2016, we can expect to see HRSA propose a new rule surrounding the 340B Program’s administrative dispute resolution process. It is said that this proposal will apply to both the drug manufacturers and covered entities.

In addition to the above, our research also states that the HHS Office of Inspector General (OIG) also has plans for this year that involve the 340B Program. One plan of action is to take a look at Medicaid managed care organizations that pay for drugs purchased through the program and determine the risk of duplicate discounts for them. An explanation on the efforts that will be taken to prevent this is also said to be on the horizon.

To learn more about the expected future for 340B in 2016, check out the full article from Health Care Law Today here. 

At PBIRx, we are heavily involved with the 340B Program and offer our own independent compliance audits along with ongoing management, which include monthly compliance audits and updates to Policies and Procedures documents.    These services ensure that our clients will maintain their 340B status. For more information about this service, as well as our participation with the program, please visit www.pbirx.com or call (888) 797-2479.