Telemedicine Prescription Cost Effect on the Pharmacy Benefit

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

As a company whose main priority is to stay on top of the latest news and drivers of pharmacy cost, we find it increasingly important to discuss the increase in prescription drug utilization effect that the telemedicine market is predicted to have on pharmacy benefit costs, which is one reason why so many chain pharmacies are getting actively involved in offering telemedicine services.

For those of you who are unfamiliar with the term, the American Telemedicine Association defines telemedicine as the "use of medical information exchanged from one site to another via electronic communications to improve a patient's clinical health status." Directly related to this term are "telehealth" and "teladoc," which also revolve around the idea that health professionals and services can be accessible to patients through electronic mediums rather than just face-to-face and have the ability to prescribe drugs as a solution to the described patient illness.

In recent news, there have been several pieces of legislation proposed regarding the extent to which telemedicine can be applied. For example, two United States Senators just introduced a bill that would permit health professionals working in Veterans Affairs (VA) facilities to treat their patients using the technology that is associated with telemedicine, regardless of the state. Additionally, this past summer Delaware introduced a new law that outlined how telemedicine can be practiced within its borders.

That being said, it is important to carefully analyze how prescription utilization (number of prescriptions for each person) is going to increase as many carriers begin to expand their use of telemedicine. Walgreens and MDLIVE, for example, recently began offering telehealth services in three new states, with the expectation that 25 states will have access to them by the end of 2015. Part of their offering is that remote doctor access is available for just $49.00 a visit. Additionally, CVS announced this past summer that they will be working closely with telehealth companies American Well, Doctor on Demand and Teladoc to make telemedicine programs more available to patients. 

With all of these changes taking place, one must be prepared for an increase in the number of prescriptions written since telemedicine services are much easier to access than making an appointment with patients' primary care doctors. As a result, entities providing pharmacy benefit services to their members or employees need to benchmark, not only the date that they offer telemedicine services, but also the prescription utilization to see how such utilization changes/increases as compared to when telemedicine services were not available. All PBIRx client profiles document if the telemedicine services are offered, by whom and on what effective date so that our analysts can better understand prescription utilization increases, which is a pharmacy benefit cost driver.

For more information about the telemedicine market and how your pharmacy benefits may be affected by its growth, please give us a call at (888) 797-2479. Additional information about how we can help you with your pharmacy benefits can be found at www.pbirx.com.

PBIRx Is LIVE On Social Media

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

When you need information about pharmacy benefit plans, drug costs, health care reform and other similar topics, you need PBIRx. As a pharmacy benefit consulting and auditing company that works with a number of clients on their pharmacy benefits, we have dedicated ourselves to becoming a leading source of information on all subjects pertaining to the pharmaceutical and health care industries. 

To share our knowledge and expertise with others, we are active on the following social media sites:

Facebook

Twitter

Google+

LinkedIn

Last, but certainly not least, there is also our blog! From new FDA drug approvals to overviews on certain drug types and insider news, we have the details you need to stay up to date on the ever changing nature of our industry. And the best part is, you can subscribe to our blog via email so that you can be the first to know when we have published a new post. It's simple! Just enter your email address in the corresponding box on the right hand side of our blog's homepage.  

To learn more about the PBIRx team and how we can help you through our consulting and auditing services, please give us a call at 1 (888) RxPBIRx (797-2479). And don't forget to visit us on our website! We recently updated the layout and design, making it much more user friendly so that you can access everything you need with ease. 

Pharmacy Benefit Actuarial Services At PBIRx

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

If you are an entity that provides pharmacy benefits to its employees or members, then we know your primary concern is likely taking care of those who are currently still active in your place of work. But, if you also offer pharmacy benefits to employees who are retired, then it is important to be aware of the aid you may be eligible to receive from the government.

The Retiree Drug Subsidy Program is an opportunity available through Medicare that allows providing entities to continue offering eligible retirees employer sponsored coverage similar to what they received as an active employee. According to the Centers for Medicare and Medicaid Services, "it is generally considered the easiest and most straightforward of the available options, and can often be implemented with little or no benefit design changes to current coverage." That means that those who qualify are likely to be able to receive the same pharmaceutical services they once did even though they are no longer in a position of employment.

To be eligible for the reimbursement (as of January 1, 2006, the government provides a 28% drug subsidy for qualified plans), the Pharmacy Benefit Plan must be equal to or better than the Medicare Part D plan. Furthermore, it is required that an evaluation is completed and signed by a certified actuary, and an application must be submitted to the RDS program 90 days before the plan becomes effective.

How We Help

Here at PBIRx, we have dedicated a division within our company, Pharmacy Benefit Actuarial Services (PBAS), which handles the entire application process for clients seeking the Retiree Drug Subsidy. We have a team of actuaries who possess the certifications needed that can guide you through each of the necessary steps in order to determine your eligibility and ultimately, to receive the subsidy if approved. Below is just some of what we will do to get started:

• Provide a courtesy review of date including estimated subsidy amount and estimated PBAS services fee.
• Determine if your plan is eligible.
• Determine if a modification of the plan will make you eligible if you are not already eligible.
• Communicate all employer paperwork deadlines required by the government.
• Develop and participate in a communication strategy for your Medicare eligible employees.

To find out if you are eligible and move forward with the process, we encourage you to give us a call and set up an appointment for your FREE consultation!

For more information, please visit us at www.pbirx.com or contact us at (888) 797-2479.

Pharmaceutical Industry Acronyms Defined

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

Have you ever tried to read a piece of literature, only to learn that you were unfamiliar with many of the terms within? Although you may have an idea of what you are reading, it can be difficult to fully grasp all concepts when you are unclear about terms and phrases that are used over and over again.

Specifically focusing on the pharmaceutical industry and the nature of our work, we at PBIRx realize how complex it can be for current clients, prospective clients and those simply seeking information about what we do to understand the texts they come across. With so many variations of different laws and guidelines, and a multitude of acronyms used to define benefit plans, treatments and more, there is so much that needs to be learned before one can become truly familiar with all that they see and read.

To help clear up any confusion, we have outlined a few of the most common acronyms our team uses along with their definitions:

CMS: CMS refers to the Centers for Medicare and Medicaid Services. To learn more about this government agency and its role in health care, click here.

CTIRx: This term is especially important for our clients to know! CTIRx (Clinical Technology Intelligence) is one of our own proprietary offerings with over 100 clinical algorithms used with our client’s actual utilization to identify programs resulting in significant savings. It is a division of PBIRx that works to recommend clinical cost savings opportunities and facilitate program implementations with doctors and members. We also measure the actual savings as compared to estimated savings provided to our clients.

HIPAA: HIPAA is an acronym for the Health Insurance Portability and Accountability Act of 1996. This act is voluminous and provides protection to American workers including:

• Limited exclusions for medical conditions that already exist.
• Offering new rights that permit individuals to receive health coverage in various situations, such as when they get married or lose previous coverage.
• Prohibiting discrimination in terms of both enrollment and cost based on factors pertaining to health-status.
• Major restrictions on the protection of Patient Health Information (PHI)

But that is not all! Learn more here.

OTC: OTC stands for over the counter, meaning you are not required to provide a prescription to buy the medicine. Some examples of over the counter medicines (or non prescription medicines) are Advil, Claritin and Tylenol. 

PMPM: PMPM is the acronym for per member per month. Typically looked at and determined on a monthly basis, this refers to the ratio of service or cost for the number of employees in a group.

If you are in charge of your company's benefits, these terms are extremely important to know as they will likely be mentioned in various conversations and within several documents that you receive. But should there be other terms that you are still unsure about, we want to define them for you right away! To have your questions answered, be sure to visit us on Facebook or Twitter to let us know what still needs to be clarified.

Here at PBIRx, we are dedicated to making sure that our clients are familiar with the information they are presented every step of the way. For more information about our services and how we can help you next with the management of your pharmacy benefit plan, please give us a call at (888) 797-2479.

Entresto® FAQs

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

What is Entresto®?
Entresto® (sacubitril / valsartan) is a combination of two oral agents used for the treatment of heart failure. It belongs to a new class of drugs called the ARNI’s (angiotensin receptor and neprilysin inhibitors).

What is special about this drug?
One of its two agents – sacubitril - is a new type of drug that, in combination with valsartan, has been shown to have efficacy over existing heart failure treatments.

How much will it cost?
Expected cost is $15/day; $5000/year.

Is Entresto® currently available? 
Entresto® is expected to be on the market 3Q15.

How many people will use Entresto®?
Heart failure affects 5.7 million Americans. Over 800,000 cases are newly diagnosed each year. Entresto® has an estimated market of over 2 million U.S. lives.

What are the current drug treatments for heart failure?
Heart failure is currently treated with a series of older agents, most available generically. They have varying degrees of efficacy and side effects.

Is Entresto® safe?
Initial testing did not reveal any unknown side effects versus the therapy it was tested against. As with any drug there is the potential of side effects and adverse events. As new drugs are dispensed to a wider population we can expect more reports of side effects and adverse events.

What will the FDA do to ensure drug safety?
The FDA has required post-marketing studies to observe certain adverse trends noted in the drug testing.

For more information, please contact PBIRx at (888) 797-2479.

PCSK9 Inhibitors

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

What are PCSK9 Inhibitors?

PCSK9 inhibitors are a new class of drugs that can greatly reduce LDL (Low Density Lipoprotein) cholesterol levels.  LDL is the “Bad Cholesterol” associated with increased risk of heart disease, including heart attack and stroke.

What does PCSK9 stand for?

PCSK9 stands for Proprotein Convertase Subtilisin Kexsin 9.

How much do they cost?

We do not yet know the specific cost but do know they will initially range about $6-12K per year.

Are these drugs currently available?

Two different brands of this drug Praluent™ (alirocumab) and Repatha™ (evolocumab) will be approved third quarter 2015.

What does the FDA say?

The FDA has not formally approved these drugs for market. It is highly expected they will formally approve this drug in the coming months. An FDA medical advisory committee has recommended approval of these drugs for certain conditions.

Are the PCSK9’s for everyone with “high cholesterol”?

No.  As of today, the FDA medical advisory committee has unanimously recommended use of these drugs in people with HoFH (Homozygous Familial Hypercholesterolemia). This is a rare genetically induced high cholesterol disorder that affects 1 in 2000 people.

Additionally the committee was split for recommendation for use for people with any other indication for these agents.

Other indications include:

All patients with high LDL cholesterol

Patients that are “statin resistant”

Patients that are “statin intolerant”

Why is the FDA advisory committee not unanimous for these other indications?

All the data is not yet available. Studies to date have proven that these drugs will reduce LDL by up to 60%. While in theory this is a good sign, it has yet to be shown that this will result in lower heart disease rates.  Two studies involving 20,000 patients are currently under way but the results will not be avialable until at least 2017.

Why the caution?

Historically other cholesterol reducing agents have been approved based upon their cholesterol improving abilities, but later studies showed limited outcomes benefits. These agents include niacin, fibrates and Zetia™ (ezetimibe). While they have all found a place in the cholesterol lowering arsenal their actual results are much less then the initial studies had shown.

Are there other concerns?

Yes.  As with any other newly approved drug there is an unknown side effect adverse event profile. New drugs are studied in controlled populations. After drugs come to market they are exposed to a much greater cross section of the general population. Invariably unknown issues come to light. What is known to date is that the PCSK9 inhibitors have shown a greater degree of “cognitive dysfunction” vs. placebo.  While not statistically significant in the limited studies to date, it is an issue of concern for the FDA advisory committee.

Additionally theses drugs will initially be available only in a subcutaneous injectable form. Similar to Insulin in administration, they will be administered either once or twice monthly depending on the PCSK9 dispensed.  Historically there is some resistance to injections from a portion of the population. An oral version of this drug is currently under study.

Are PCSK9 drugs a “cure”?

No. These agents will lower LDL cholesterol levels but will not treat the underlying causes. This means that these drugs, and any other cholesterol lowering drugs, must be given for the lifetime of the patient.

What is the current treatment for lowering cholesterol?

The drug class of choice is the “Statins”, for which there are many low cost generics available.  This is a class of drugs with proven effectiveness in lowering LDL. While highly effective there is a subset of patients that are resistant to the positive effects of statins and others who suffer from its side effects, primarily muscle pain.

How much do statins cost?

Generic statins cost around $100 per year. Crestor™(rosuvastatin), a brand statin, can cost around $450 per year.

How many Americans have “high cholesterol”?

70 million Americans have high LDL.

Are there other means of lowering cholesterol?

Yes.  Diet, exercise and stress control are all contributing factors and can be controlled, or mitigated, by lifestyle changes.

What does PBIRx recommend?

At this point in time we recommend restricted use of these medications only for those with HoFH, or patients at high CV risk that are statin intolerant or statin resistant. We work within the guidelines of the American College of Cardiology and American Heart Association as to the definition of these conditions.

Our recommendation is to only allow use of these agents with a Prior Authorization from your PBM, after consultation with the patient’s doctor.

Because of the potential costs involved we believe you, the payer, have a right to know that this drug is being prescribed under the most optimum conditions and being used correctly and appropriately. 

As these are a new class of drugs, with multiple competitors, incoming information is evolving rapidly, and criteria and situations may change. As your pharmacy consultants we strive to be aware of this evolving landscape and will keep our clients informed. 

New Cystic Fibrosis (CF) Drug Expected To Receive FDA Approval

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

PBIRx wants to inform you that a new Cystic Fibrosis (CF) Drug, Orkambi (lumacaftor-ivacaftor), is estimated to be approved by the FDA July 5th with a potential cost of $287K per year per utilizing member.

What you may want to know about the drug is the following:

• Only 28% of CF patients (8,500 in the U.S) have the correct genotype for Orkambi to be effective. By comparison, Kalydeco (ivacaftor), another FDA approved CF drug, is effective in 4% of CF patients, (2,000 in the U.S), has been on the market for over a year, and costs about $300K per year per patient.
• The latest information we have is that the FDA Advisory Panel recommended Orkambi for approval, and $287K is the estimated annual wholesale cost. Once patients are started on this drug, they can be expected to continue for the duration of their lives.
• The two active ingredients, lumacaftor and ivacaftor, work together to alleviate the defect of the mutated gene in two steps. Lumacaftor corrects interaction with the CFTR protein and ivacaftor potentiates the effect to keep the CFTR open at the cell surface.
• In a study published in the New England Journal of Medicine, the impact of the drug was as follows: an increase in lung function of 2.6 to 4.0% and a decrease in the rate of pulmonary exacerbations by 30-39%.
• The issue for plans is that only those members being treated for CF with the specific CFTR gene mutation should be treated with this combination drug.  The concern is that some prescribers will try this drug before confirming genotype and the drug will be ineffective at a cost of about $25K/month. This was seen when Kalydeco first came on the market.
• PBIRx Clinical agrees that this drug is a clear candidate for a Prior Authorization strategy, to confirm use only in appropriate members.

What you may want to know about the disease CF is the following:

• There are 30,000 estimated CF patients in the U.S.
• Cause of the disease is a mutated CFTR gene causing thick, sticky mucous which impairs breathing. This results in inflammation and recurrent pulmonary bacterial infections, and sometimes death.
• CF is a hereditary disease.  When both of the two CFTR genes in a person have mutated, the person will have CF.  If just one gene mutates, the person is a carrier for subsequent generations.
• CF affects mostly the lungs, but the pancreas, liver, intestines, and kidneys can also be impacted.
• While in 1955 the median age of survival with CF was 5 years, by 1985 it was 25 years, and by 2012 it became 41 years.
• Current treatments include: vitamins; painkillers; antibiotics; and Kalydeco (for 4% of CF patients) to maintain daily activities. 

For more information about this new drug and how it may affect your pharmacy benefit plan, please give us a call at (888) 797-2479.

Clinical Technology Intelligence (CTIRx) By PBIRx

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

At PBIRx, we are all about finding ways to minimize healthcare costs by developing cost saving solutions that each of our many clients can benefit from. Aside from our consulting and auditing services, one of the major benefits we offer is our clinical technology intelligence, also known as CTIRx. Through this service, our goal is to promote clinically appropriate prescription drug utilization, which in turn results in positive healthcare outcomes (including pharmacy benefit savings, of course).

To ensure that our clients are paying the appropriate prices for pharmaceutical services, we run their claims through our CTIRx data processor. Then, we carefully analyze the results to determine what steps must be taken next in order to present our clients with the most beneficial clinical savings programs.

But what exactly are we analyzing?

Throughout the process, we complete a monthly analysis of cost and claims for all types of prescription drugs, review physician prescribing practices and manage specialty spend by following along with the steps presented in our specialty drug tool box. Furthermore, we analyze the cost of prescriptions through medical J code and compare that to the pharmacy benefit, and determine how we can alter drug dispensing to further benefit the client.

Since pharmacy benefits are so complex by nature, we have made it our priority to offer providing entities the services they need to ensure that what they are spending accurately reflects the lowest possible prices. For more information about our CTIRx services and how we can help you manage your pharmacy benefit costs, please visit our website or contact us at 1 (888) RxPBIRx (797-2479) today.

How Can PBIRx Help You?

PBIRx®

Intelligent Solutions in Pharmacy Benefits

612 Wheelers Farms Road, Milford, CT 06461

(888) 797-2479

Since 1990, PBIRx has been working to control pharmacy benefit costs and create optimal health care outcomes for employers, institutions and third party administrators who provide pharmacy benefits to their employees or members. Using proprietary algorithms and cutting edge technology, our esteemed group of consultants with years of experience in the pharmacy industry are dedicated to finding solutions for our clients that result in a reduction of their overall health care costs. In doing so, we make it our priority to make sure that each client is treated individually and a strategic plan is developed along with estimated savings based on specific agreed upon needs and goals. The original estimated savings is reported back to our clients on a quarterly basis to be sure that we are delivering the savings that we promised!

But how do we do it? At PBIRx, we offer a variety of services to aid in the management of your pharmacy benefits. As a leading pharmacy benefit auditing and consulting firm, our staff closely analyzes your current pharmacy benefit plan. Then, using a combination of the latest technology and our own proprietary programs, develops a strategy to reduce the cost without eliminating any of the benefits your employees or members are receiving at the time. Further, we constantly seek out clinical and other cost saving opportunities and work to make sure that the terms and discounts stated in your plan are an accurate and competitive depiction of the pricing options currently available in the industry.

See below for a comprehensive list of the services that we offer here at PBIRx:

• Pharmacy Benefit Consulting
• Pharmacy Benefit Auditing (AuditRx)
• Pharmacy Benefit Actuarial Services
• Third Party 340B Compliance Audits
  Allocation Rate Projections
• Clinical Technology Intelligence and Algorithms
• Rebate Aggregation

Since pharmacy benefit plans and the terms outlined within are extremely complex, changing often and difficult to navigate, it is important for entities to connect with an expert like PBIRx to make sure that their plans are designed in a way that produces only the best results for the entity and for those that they provide benefits for. Are you ready to get started? To learn more about our services and how we can help, please visit us at www.pbirx.com or give us a call at (888) 797-2479 today.