Anthem Express Scripts’ Lawsuit Should Incentivize Municipalities to Seek Independent Pharmacy Benefit Consulting Firm

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

Pharmacy benefit lack of expertise by using a Medical/Employee Benefit consultant, Carrier or TPA, versus an independent pharmacy benefit expert like PBIRx, hits municipalities’ and taxpayers’ bottom line. There is so much money left on the table and no one seems to care! 

After several attempts at negotiation and using an independent third party pharmacy benefit expert, Anthem is now suing Express Scripts for an estimated $13 billion in overpayment of pharmacy benefit costs. If Anthem is using an independent pharmacy benefit expert, why are the many municipality clients they serve not doing the same? Why are their municipality clients not concerned about what percentage of the $13 billion that Anthem is trying to get from Express Scripts is representative of their budget? Does anyone think that if Anthem gets a concession from Express Scripts that Anthem will credit the pharmacy benefit costs for their municipality clients? We do not think so!

Municipalities typically go out to bid for their medical benefits by requesting an RFP for a Health or Other Employee Benefit/Medical Consultant or their TPA/Carrier recommends a PBM; however, they rarely request an RFP for an independent Pharmacy Benefit Consultant, even though pharmacy costs now represent up to 30%-40% of total employee benefit costs and is increasing annually.     

Taxpayers, just like us, have no idea what is going on at our local Town Hall or Board of Education even though our taxes go up every year for the rich benefits that municipal workers and their unions demand. With an independent Pharmacy Benefit Consulting firm like PBIRx, municipalities’ budgets would benefit, while employees and union members maintain their benefits and taxpayers save money…a win, win, win situation!

An Employee Benefit, Medical Consultant, Carrier or TPA cannot possibly know and follow all the complexities that are involved and constantly changing in pricing for the pharmacy benefit, along with the ability to analyze and audit like an independent Pharmacy Benefit Consulting firm. Employee Benefit/Medical brokers/consultants and TPAs/Carriers typically go the easy route of a spreadsheet, when like most things, i.e. the PBM profit, is buried in the details in the Pharmacy Benefit Agreement or when using a TPA or Carrier “very little” information related to the pharmacy benefit pricing is stated in the TPA or Carrier Agreement.    

Auditing the pharmacy benefit, which is integrated in with the medical TPA or Carrier, is almost impossible because of the lack of language and calculation methodology of pricing in their TPA/ Carrier Agreements. Even when municipalities contract directly with a PBM, they rarely audit that Pharmacy Benefit Agreement, which typically allows only auditing of the previous 12 months, even though pharmacy benefit drug spend is in the millions of dollars.  An independent Pharmacy Benefit Audit will also provide information related to the competiveness of the PBM contract.

For over 25 years, PBIRx, an independent third party Pharmacy Benefit Consulting and Audit Company, works directly with municipalities and has “Strategic Broker/Consultant Partnerships”, as well as “TPA Strategic Partnerships”. These PBIRx Strategic Partners understand  the need to work with an expert that employs a staff of mature and seasoned professionals with a sole focus only on pharmacy costs. To speak with one of  the PBIRx experts and learn how you can be helped next with your pharmacy benefits, please visit www.pbirx.com or call (888) 797-2479.

Do You Know The Games That Your PBM Plays Behind YOUR Back?

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

As an entity that provides pharmacy benefits to its employees or members, it is absolutely critical that you fully understand how your PBM operates after a deal has been made and your contract has been signed. Though you may feel confident that the terms and agreements proposed and negotiated will be upheld, it is not unusual for PBMs to fail to comply. Compliance failure can be due to several factors including lack of knowledge by not using pharmacy benefit consulting expertise, such as those provided by PBIRx, human error in setting up and modifying contractual details, system changes when PBMs merge or are acquired, etc. These compliance failures result in unnecessary increased costs as PBMs work to increase their own profitability.

Take the recent Novartis Kickback Scheme as an example. As reported in an article by the Wall Street Journal, allegations were made against Novartis for offering patient referrals to Accredo Health Group in exchange for encouraging refills of Exjade. Essentially, Novartis is claimed to have offered some type of financial benefit to the specialty pharmacy (which is run by Express Scripts) in order to boost sales of their products and therefore increase their profit.

Further explained in an article from BioPharmaDIVE, the arrangement between Novartis and Express Scripts is said to have lasted for four years (from 2008-2012) and caused Medicare, Medicaid and other similar programs to be "defrauded." Meaning, money was obtained illegally from these programs through the alleged deceiving actions of Novartis and the specialty pharmacy Accredo Health Group.

To put an end to the accusations, Express Scripts has officially agreed to pay $60 million dollars. But will will this be the last time a kickback scheme like this occurs?

Though unfortunate, it is important for all benefit providers to be aware of the possibility that their PBM is prioritizing the profits of the stockholders, versus lowering and managing the growing costs associated with the pharmacy benefit. That is why we place such an emphasis on auditing pharmacy benefit plans! By meeting with an expert team like PBIRx, entities can rest assured knowing that they are not falling victim to a scheme that is costing them more in the long run.

For more information about our pharmacy benefit auditing and consulting services, please visit www.pbirx.com or contact us at (888) 797-2479 today.

Express Scripts Makes Major Staffing Changes

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

Express Scripts Holding Co., one of the largest publically traded PBMs, is continuing to make major changes to their executive level employees. Most recently, Eric Slusser, former CFO of Gentiva Health Services Inc., was appointed CFO almost immediately following the retirement announcement from Express Scripts’ CEO of 11 years George Paz - Slusser’s news broke just a day later. With a background that includes executive experience with Centene Corp. and Cardinal Health Inc., Slusser’s projected earnings are upwards of $2.75 million.

As for CEO George Paz, he will officially step down from his position in May of 2016, although he will still remain involved in the company as a non-executive chairman. His replacement is Tim Wentworth, who is currently Express Scripts’ president, according to NASDAQ. Wentworth’s resume includes experience with Mary Kay, Inc., PepsiCo, Accredo and Medco - prior to Express Scripts’ acquisition of Medco, he was with the company for 14 years and was the president of Accredo (Medco’s specialty pharmacy).

So what does all of this mean for those who use Express Scripts as their pharmacy benefit manager? As a company that manages $1 billion prescriptions for an approximate 85 million people every year (via ABC News), these changes will certainly require the PBM to place their focus on continuing to grow their profits - and at the cost of plan’s health care budgets at that. Therefore, it becomes increasingly more important for providing entities to seek the help of an expert like PBIRx, which is INDEPENDENT from the PBM and whose focus is to lower the PBM profit and increase your pharmacy benefit budget, which is at risk with the increase of high cost drug prescribing.

Here at PBIRx, we can review your pharmacy benefit contract and ultimately oversee your plan’s management to ensure that all actions provide you with the greatest benefit rather than the PBM.

For more information about our pharmacy benefit consulting and auditing services and how they can help you achieve optimal health care outcomes while minimizing overall health care costs, please visit our website or contact us at 1-888-RxPBIRx (797-2479).