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.

Cost of Praluent for High Cholesterol Announced

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

Those who suffer from high cholesterol may soon have a new treatment available to them - but at a very high cost to the Plan Sponsor. Praluent, a PCSK9 inhibitor developed by Sanofi and Regeneron Pharmaceuticals Inc., recently received FDA approval to be used for the purpose of lowering cholesterol and will be available through a limited number of specialty pharmacies. As reported by CBS News, it is "considered the first major advance in cholesterol treatment since statins were first introduced more than 20 years ago." However, though this may be a major breakthrough for certain patients who struggle with cholesterol on a daily basis, the benefits it can bring will come at a high price.

Designed to be injected into only a subset of patients who meet very specific criteria for this treatment, it was announced that Praluent will cost $40 for every day of treatment, which comes out to a whopping $14,600 per year. Unfortunately, this cost is higher than the already costly predictions - most were in the $10,000 range according to CBS. 

In addition to this new drug, also keep an eye out for another new PCSK9, which is due to be launched within the next 60 days and two other PCSK9s are expected to follow in 2016.

What this means for you...

For entities that provide pharmacy benefits to their employees or members, the introduction of this drug could certainly impact your plan and the price you pay for certain services if you provide pharmacy benefit coverage for individuals who require cholesterol lowering treatments. Of particular interest is the diversity amongst Pharmacy Benefit Managers pertaining to the clinical protocol for approval of PCSK9s along with some PBMs that are encouraging or mandating mail order only and/or offering a Per Member Per Month fee for PCSK9 Program clinical services. As a result of Pharmacy Benefit Manager increased costs for prior authorization, a Per Member Per Month Fee and the increased utilization of this high cost drug, Plan Sponsors will inevitably feel the effects of higher pharmacy benefit costs.

On another note, for covered individuals, this approval could also mean an increase in their cost share/copayment versus generic statins, another cholesterol treatment, which are known to only be about $100 per year.

As experts in the pharmaceutical industry, the team here at PBIRx is constantly working to find out how our current clients and future clients will be impacted by new drug approvals. Therefore, to learn more about how you may be affected when this new drug makes its way to the market, give us a call at (888) 797-2479 or visit us on our website to learn how our pharmacy benefit consulting and auditing services can help you in more ways than one.

Connecticut Pharmacy Benefit Consulting Services

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

With recent news suggesting that the cost of both specialty and prescription drugs is continuing to rise, the need to control such costs is pressing now more than ever. Furthermore, as the cost of services increases, entities that offer benefits, and specifically pharmacy benefits, will need to ensure that their PBMs are acting according to the terms and agreements in their plans; otherwise, they might be losing out on critical rebates and discounts! PBM contract audit language only allows up to 12 or 18 months that you can audit with a 90 day notice. If you do not follow the guidelines in your PBM contract you will lose the opportunity to audit and potentially leave 5% - 20% of your pharmacy spend in added profit to the PBM.

If you offer pharmacy benefits to your employees or members, we highly recommend connecting with an expert consultant like us to have your plan analyzed. Here is what we will do as part of our pharmacy benefit consulting services:

• Evaluate your current pharmacy benefit plan, including its design and the costs that you are currently subjected to.
• Identify where rebates and discounts are not being offered when they are available.
• Recommend a new plan design that more accurately reflects the lowest prices for your desired healthcare outcomes.
• Develop a PBM RFP negotiation strategy.

As we go through and analyze your plan, we will always present you with an unbiased, objective financial analysis that shows sensitivity to both the member and the client. For more information on how we can help create optimal healthcare outcomes for you and your members while reducing overall healthcare costs, please click here.

Located in Milford, CT, PBIRx's goal is to help you get more control over your healthcare costs. With a team of actuaries, analysts, clinicians, compliance officers and more, PBIRx always focuses on the clients' best interest rather than the PBM to ensure that they are not paying anymore than they need to be for desired healthcare outcomes. For more information, please call (888) 797-2479 or email info@pbirx.com.

PBIRx Service Overview

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

For over a decade, the team here at PBIRx has been assisting clients with the management of their pharmacy benefit plans to ensure that they are receiving desired healthcare outcomes at the lowest possible cost. Since pharmacy costs can represent 16% to 40% of of all healthcare costs today depending on demographics, and since the costs of drugs and services are ever changing, entities that provide pharmacy benefits must remain in tune with the changes to ensure that the pricing in their PBM contract is accurate and up to date; this is exactly where we come in!

When matched with our own proprietary algorithms and similar cutting edge technology, the expertise and knowledge of our diverse staff allows us to create cost saving solutions for our clients with regards to their pharmacy benefit plans. Although you may assume that your plan will be carried out following the terms within, the truth of the matter is that there are instances where either your PBM is not adjudicating claims according to your contract terms or you are not receiving the rebates and discounts that are more competitive from the start. The following is just a brief overview of the services we proudly offer to assist you in these areas:

• Pharmacy Benefit Consulting
• Pharmacy Benefit Auditing (Using Audit Rx)
• Pharmacy Benefit Actuarial Services
• Third Party 340B Compliance Audits
• First Fill Optimization
• Clinical Algorithms To Detect FWA and Gaps Of Care
• Rebate Aggregation

Within each of these services, we will carefully analyze your current plan and see where your PBM has drifted from the agreements stated in your contract. Should adjustments need to be made, we will recommend modifications and new plan designs using the most up to date information about pricing as it relates to the healthcare services you currently receive. And the best part is, you will not have to sacrifice any of your desired healthcare outcomes to receive certain rebates and discounts; we will find you the savings you deserve all while maintaining the pharmaceutical drugs and services you are entitled to through your plan.

Have you yet to have your plan analyzed for potential discrepancies in terms of cost? If so, don't wait, connect with an expert like PBIRx today. To learn more about our services, please visit us on our website or give us a call at (888) 797-2479.