Monday, December 29, 2014

PBM Myth: The Request For Proposal (RFP) Binds Your Pharmacy Benefits Manager

Many times clients go through great effort putting together an RFP for PBMs to answer in great detail questions about pricing, service level, and others.  Herein lies the problem; little of this pricing information gets put into the contract.  Those 25 pages or more of useless information could've been put to better use by reducing your carbon footprint.

If a PBM expects to gain your trust and manage your pharmacy benefit, it is only reasonable they sign a fiduciary contract which reflects their claims to transparency. If the PBM agrees to your terms, it only follows that your plan goals are memorialized in a rock solid contract.

RFPs do not bind a PBM to their guarantees, fiduciary contracts do. You must eliminate the RFP process and instead draft an airtight fiduciary contract and put it out for bid. A contract is not a legal agreement until it is signed by all parties involved.  Consider this;
  • Many times financial guarantees are not guarantees unless the client has spelled them out in a fiduciary contract. 
  • All rebates may not be paid unless a fiduciary contract is signed.
  • Full audit provisions generally will not be honored unless you have a signed fiduciary contract and a RFP is not a contract. 
However, a signed agreement in a well drafted contract that honors the best that a PBM can offer through the RFP process is worth celebrating with concrete savings. The best type of contract, without question, is a fiduciary contract. Fiduciary contracts provide the highest level of care and deliver perpetual cost reductions to plan sponsors. That being said, why would you settle for anything less?

Click here to register for: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels."

Monday, December 22, 2014

Bitter Pill: Drugs Work But Drive Overall Cost

As the year winds down, many employers are reviewing 2014 expenses to help plan spending for the new year. One of the main expenses for many organizations is the cost of employees’ health care. These costs seem to go up every year, but why?

According to America’s Health Insurance Plans, a national trade association, health care spending nationwide rose at its fastest pace in 10 years in the fourth quarter of 2013. The main reasons are the rising costs of medical services such as hospital care, costly new drugs and medical technologies, and the impact of hospitals and physician offices consolidating, leaving less competition.

One of these reasons may surprise employers — the availability of new and costly prescription drugs, also known as specialty drugs.

Specialty drugs are used to treat complex conditions such as cancer, cystic fibrosis, hemophilia, multiple sclerosis or psoriasis. You may have seen advertisements or news reports about the drugs Humira for treating inflammatory conditions such as rheumatoid arthritis or Crohn’s disease, and Harvoni for treating hepatitis C.

Specialty drugs are usually injected or infused, but also may be taken orally. And many of these drugs show great results in treating complex, chronic conditions and allowing patients to live fuller, longer lives.

Specialty drugs are used to treat serious conditions and can be complex to manufacture, the cost can be significant. The 2014 EMD Serono Specialty Digest reports that 3.6 percent of patients who use specialty drugs account for 25 percent of health care costs.

Data from Express Scripts, a national pharmacy benefits manager, shows the average cost of filling a specialty drug prescription for one month is $1,800 compared to $54 for other prescription drugs. CVS Caremark also projects that the costs of the entire specialty drug market will reach $402 billion by 2020. Thanks to advanced research, more than 900 specialty drugs are in various stages of development.

Knowing that an employee who has a complex medical condition such as cancer now has access to new and better treatments is certainly good news. But employers must understand that when health care costs increase for employees, so do health insurance premiums. The National Institute of Health Care Management Foundation attributes 97 percent of the rise in premium spending between 2006 and 2010 to increased spending by insurers to cover the actual health care costs of members.

We encourage employers to be aware of the drivers of health care costs and health insurance premiums and to work with their insurer to help manage those costs. [Publisher Comment:  work with your insurer to better manage rising prescription drug costs, but utilize the services of a PBM expert, internal or external, to hold the insurer/TPA accountable.  Insurers will surely take advantage of gaps in your knowledge in order to maintain their profit.]

For example, many health insurers implement utilization management procedures to help ensure that members receive coverage for the right medications to treat the right conditions. Many insurers work with employers to offer workers access to lower cost generic drugs when appropriate, and most also offer case and disease management programs to help chronically ill workers stay on track with self-management.

At Blue Cross of Northeastern Pennsylvania, we utilize a team of clinical professionals, including pharmacists, doctors and nurses, to conduct reviews of specialty drug use to ensure that our members have coverage for appropriate medications to treat their complex conditions. This review also helps ensure that specialty drug treatment is working effectively and is helping the member get better.

As 2014 comes to an end, employers should take the time to review their health care costs and work with their insurer to find ways to better manage those costs, including understanding two of the biggest drivers of health care costs — specialty and prescription drugs.

By Nina M. Taggart, M.D.

Sunday, December 14, 2014

The Rising Cost of Generic Prescription Drugs is Even Puzzling Experts

Source: Pembroke Consulting
For decades, generic prescription drugs have been considered the bargains of the pharmaceutical world. An industry group says Americans have saved more than $1.5 trillion in the past 10 years on brand name drugs, thanks to generics. But in recent months, prices on some of the most popular drugs have soared, and experts are trying to figure out why.

Buying generic prescription drugs feels like trading on the stock market for Cory Minnick.
"Just seems to snowball every month, it gets worse and worse. You see stuff you used to buy for pennies for a hundred, and now you're paying $70 to $80 just to get it in," he says.

Minnick, pharmacy manager at Royer’s on Sharp Avenue in Ephrata, Lancaster County, says he’s constantly checking with his three wholesalers to see what it’s going to cost to get a drug in the hands of a customer.

The popular antibiotic doxycycline is used to treat common problems like urinary tract infections and pneumonia. 

It cost a mere $20 for a 500 pill supply in October 2013. Yet this past April, its price had hit more than $1,800. Don’t do the math on the percentage increase, it could get ugly.

By the way, doxycycline has been on the market for 40 plus years, and the formula hasn’t changed. So what’s going on here?

Drugs have "life cycles"

"These recent drug shortage and price hikes illustrate a third stage of the life cycle of a drug that we haven't really paid much attention to yet," says Jeremy Greene, a Johns Hopkins professor and author of Generics: the Unbranding of Modern Medicine.

"What happens when a drug is no longer particularly attractive to generic manufacturers? Or when the interests of the generic marketplace continue to go towards the second pipeline, the pipeline of drugs that are going off patent now and the drugs that have been off for patents for a while are no longer particularly attractive and get neglected," he says.

Greene says drugs used to have two cycles – the brand name stage, where the patent protects the work done by companies like Pfizer, and helps them recoup their investment in research.

But then the patent expires, and all manufacturers have a shot to make and sell the drug, ideally, at a much lower cost.

That what Ralph Neas, President of the Generic Pharmaceutical Association is focusing on.
"It may go up 50% or a 100%, whatever it might but you’re still in the pennies and sometimes you get up to a couple dollars. A very few number are more than that," says Neas.

Here’s what we know: In 2010, the average cost of one of the 50 most prescribed generics was $13. In 2013, it hit $62. That data comes from Catamaran, which manages pharmacy benefits for 32 million people.

Why are prices rising?

A lot of theories are floating around, but the most prominent ones deal with raw material shortages and less competition.  To continue reading click here.

Written by Ben Allen

Tuesday, December 2, 2014

Pressing for PBM Transparency

Pharmacy benefit managers generally provide pharmaceutical outpatient plans, which depend on all sorts of financial concessions the PBM extracts from drug manufacturers, pharmacies and other suppliers. Those forms of direct and indirect compensation help the PBMs to keep costs to company health plans low. But the companies are often unaware of whether promised discounts are fully forthcoming because of lack of transparency.
The Department of Labor's Employee Retirement Income Security Act Advisory Committee recently approved two recommendations pushing for the department to require disclosure of both direct and indirect compensation. 
"We commend the ERISA Advisory Council on its action and we are also excited that U.S. Labor Secretary Thomas Perez has indicated his desire to ensure  those long-overdue changes are implemented," says B. Douglas Hoey, CEO of the Alexandria, Va.-based National Community Pharmacists Association. The NCPA has been locked in numerous battles with the PBM industry over adequate participation of retail pharmacies in PBM networks.
"In the past, some council recommendations have led to regulatory projects," says Michael Trupo, a Labor Department spokesman. "The department looks forward to reviewing the council’s final reports when they are submitted."
James I. Singer, the issue chairman on PBM disclosure for the ERISA Advisory Committee, says the report should be available at the start of 2015.
Three PBMs control the lion's share of the market: Express Scripts, CVS/Caremark and Catamaran. Health plans such as Aetna, Humana and United Healthcare also own PBMs. 
Allison Klausner, assistant general counsel for benefits at Honeywell International Inc., says that rebates PBMs receive from drug manufacturers for placing particular drugs on the most attractive formulary "tier" can create "conflicts of interest." That placement, she says, may have nothing to do with a drug's superior effectiveness and everything to do with a higher PBM profit margin.
In some instances, she says, plan sponsors may be fine with rebates obtained by the PBM, but may be denied access to auditing them to ensure they are getting the share they contracted for.
But Washington, D.C-based attorney William J. Kilberg, a partner at Gibson, Dunn & Crutcher who represents the Pharmaceutical Care Management Association—the PBM trade group—says the rebates PBMs obtain from manufacturers are not "compensation," and should not be subject to DOL regulation.
Nor should there be any regulation of any kind of compensation PBMs receive, he adds, as employers have many PBMs to choose from, which gives them leverage to extract whatever information they need from whichever PBM they contract with.
Industry experts, such as Patricia M. Danzon, the Celia Moh Professor at the University of Pennsylvania's Wharton School, say that manufacturer rebates to PBMs are generally disclosed and have become less of a profit maker for PBMs as plan sponsors heavily incent the use of generics, where rebates do not come into play ordinarily. 
But that trend, experts warn, may also account for the growth of another criticized, opaque practice: PBMs' use of "spread pricing" to boost profits, by which a PBM reimburses pharmacies a lower amount than it charges a plan sponsor.

Monday, December 1, 2014

The Growing Turf War over Who Can Fill Prescriptions

Drug therapy is growing more complex and costly! So-called specialty drugs are gradually displacing traditional drugs as the primary component of drug spending. The market is expanding rapidly. Only about 10 such drugs were available 20 years ago but today there are more than 300.
These drugs typically treat medical conditions that are life-threatening, chronic and often rare. Cancer treatments are the most common type of specialty drugs, making up one-third of total. Drugs for autoimmune disorders, rheumatoid arthritis, and Crohn's disease, medications for HIV and drugs for multiple sclerosis are responsible for another third of specialty drug spending.
Although only about 1 percent of drugs prescribed, specialty drugs now account for more than one-quarter prescription drug spending. This is expected to grow to 50 percent by 2020.
Specialty drug therapy costs from at least $15,000 per year, to as much as $750,000 per year. Most have no close substitutes, rendering health plans’ traditional efforts by to control costs by encouraging generic substitution largely ineffective. 
Due to these medications’ high cost, health plans carefully manage the procurement and administering of these drugs. For instance, health plans are increasingly relying on exclusive preferred pharmacy networks to reduce costs and ensure the quality of specialty drug therapy.
When drug plans create preferred pharmacy networks they negotiate for the lowest possible prices. Negotiated prices are the result of bargaining power — the ability of the drug plan to deny business to a firm if their bid isn’t favorable. Bargaining power also strengthens the ability of drug plans to demand quality-enhancing safeguards and patient protections.
As you might expect, when a new market segment displaces an old one, stakeholders in the old market understandably don’t want to be shut out. As preferred pharmacy networks have become more common, so too have the calls for lawmakers to enact laws that restrict the ability of health plans to partner with exclusive pharmacy networks. 
The less competitive drug providers lobby CMS, Congress and state legislatures to restrict the ability of drug plans to effectively negotiate for lower prices. This past January the Centers for Medicare and Medicaid Services (CMS) tried to ban preferred pharmacy networks in Medicare drug plans. 
CMS had been under pressure from pharmacy interests shut out of Medicare Part D drug plans.  Click here to read the full article by Devon Herrick.

Wednesday, November 19, 2014

5 Strategies for Managing Specialty Prescription Drug Costs

Engineered to treat complex chronic conditions such as cancer, multiple sclerosis, rheumatoid arthritis, Parkinson’s disease, and hepatitis C, specialty prescription drugs represent less than 1% of all U.S. prescriptions yet are growing at an unsustainable rate—and employers are beginning to see their impact on healthcare costs.

The Centers for Medicare and Medicaid Services estimates that prescription drug spending was 9.4% of all healthcare spending in 2012, and a large portion of that spending was on specialty drugs. In their 2013 Specialty Drug Trend Insights report, independent pharmacy benefit manager (PBM) Prime Therapeutics places that figure at 30% of total drug costs and predicts it will reach 50% by 2018.

Express Scripts’ 2013 Drug Trend Report reveals that for the top traditional therapy classes, spending will likely climb 2% year-over-year for the next three years, whereas spending on specialty medications will increase 16.8% in 2014, 18.0% in 2015, and 18.2% by 2016.

It’s no surprise that employers are looking for ways to manage the employee benefit costs of their specialty drug coverage. To help them get a handle on their specialty drugs spend and ensure their employees receive appropriate and effective care, employers—along with their health plans and other healthcare benefits partners—are exploring a combination of tactics:

1.  Integrated Pharmacy and Medical Benefits

In their article, Employers Act to Control Prescription Drug Spending, the Society for Human Resource Management (SHRM) cites a 2013 survey by Buck Consultants finding that 71% of U.S. employers spent 16% or more of their total healthcare budget on pharmacy benefits.

It can be challenging for employers to estimate their spending on specialty drugs because these drugs are sometimes billed through medical benefits—and other times billed through prescription drug benefits. The inconsistency makes it difficult to get an accurate picture of how much is being spent on specialty medications.

When employers move the administration of specialty drugs from the medical plan to the pharmacy program, they can take advantage of better care coordination that’s easier to measure. For example, instead of a doctor ordering and dispensing a specialty drug in their office and billing it as a medical benefit, a prescription drug program can manage the drug’s cost and patient’s care. These tightly coordinated activities can lead to lower costs and easier reporting.

2.  Prior Authorizations

Employers may require a prior authorization from a provider before a pharmacy can fill a specialty drug prescription. This added level of control helps making certain that patients are using the most cost-efficient and appropriate therapies.

3.  Cost-Effective Pharmacy Plan Design

Many employers are adding a specialty drug tier to pass along at least some of the cost of more expensive drugs to employees and to help track the classes of drugs they’re utilizing. When benefits are tiered, different categories of drugs require different out-of-pocket costs, and categories may be broken up into preferred drugs and non-preferred drugs, generics, and specialty, depending on the needs of the plan sponsor or economics of the formulary.

Additionally, plans may include refill policies or step-therapy protocols. Refill policies use clinical evidence to limit doses, ensuring a patient tolerates a new drug or to avoid wasting expensive medicine; step therapy requires patients to start treatment with a lower-cost alternative drug, if available, and transition to a specialty drug if the medication at the first step isn’t effective.

4.  Pharmacy Benefit Managers and Specialty Pharmacies

Many employer groups and health plans rely on pharmacy experts to help them manage their prescription drug benefit design, administration, and clinical needs, resulting in greater cost control. These companies can provide employers with the best “buys” for certain high-cost drugs thanks to their ability to leverage costs across networks and providers while providing a wide range of value-added services that can make a big impact on a company’s overall healthcare benefits costs.

5.  Utilization Management

More and more employers consider their employees’ care coordination a key element in containing costs, improving quality, and creating better outcomes, especially for those being treated for chronic illnesses.

Utilization management performed by medical professionals effectively intertwines a patient with their healthcare benefits to ensure they are maximizing their coverage and receiving medically necessary care.

By following an individual’s progress, coordinating their care, and ensuring that treatments such as prescribed drugs are appropriate, a case manager can play an important role in assuring treatment compliance, minimizing health risks, and reducing waste in healthcare spending.

Source:  Healthcare Trends Institute

Thursday, November 13, 2014

Illustrative Example of Supply Chain Pricing for Brand Name Prescription Drugs

Notes:

(1) Prices are based on a composite of several commonly prescribed brand-name drugs for a typical quantity of pills. For some cells in the table, the relative relationships have been calculated based upon our mail pharmacy and PBM operations and on other relationships widely reported by industry sources.

(2) These prices are used for illustrative purposes only and do not represent any type of overall average.

(3) Prices reported in this table include both amounts paid by third-party payers and amounts paid by the consumer as cost sharing.

(4) Manufacturers generate up to 85% gross margins on brand pharmaceuticals.

(5) The HMO column refers only to HMOs that buy directly from manufacturers.

Tuesday, November 11, 2014

Plan Controls Respond to PBM Spreads, Generic Cost Spikes

If a pharmacy benefits manager promises a group health plan that there will be no administrative fee for drugs, it actually could be a red flag and not a cause for celebration. It could mean the PBM is “gaming the spread” or not passing rebates through to the plan.

Plans can prevent this kind of leakage and contain costs much better if they take more active roles in managing drug benefits, according to Susan Hayes, who founded Pharmacy Outcomes Specialists of Lake Zurich, Ill. If a health plan abdicates all authority, it may end up losing influence and its ability to duck unreasonable price spikes, Hayes told attendees at the International Foundation of Employee Benefit Plans’ Annual Employee Benefits Conference in Boston on Oct. 14.

Contracting out drug benefit administration can make it difficult for plans to act in the sole interest of plan participants in certain ways, she said.

PBM Rebate Shifts Can Hurt Plans

Rebates and discounts between PBMs and  drug makers can reduce drug prices for plans. Several kinds of rebates exist: (1) the drug maker rewards the PBM for putting its product on formulary; (2) the drug maker rewards the PBM for allotting a certain percentage of market share to the product in relation to comparable agents produced by competing manufacturers; and (3) the drug maker pays the PBM for market intelligence on prescribing patterns, Hayes said.

But when rebates disappear trouble can start.

PBMs might say the sole reasons they rescind preferred status is because: (1) a drug has become a source of wasteful spending; or (2) clinically appropriate alternatives exist. But a drug’s removal from preferred status may be just because the manufacturer stopped paying the PBM rebates, leaving plans wondering what happened, she said.

The Spread Is No Game

A big source of potential plan waste is “spread pricing.”

The “spread” is the difference in what PBMs charge plan sponsors for prescriptions and what they in turn pay pharmacies to dispense those prescriptions. This difference often leads to greater profits for the PBM at the expense of employers. The spread is a prime contributor to why one pharmacy may charge your plan very little and another may charge very much for the same generic medication.

According to reporting by Fortune magazine reporter Katherine Eban, Meridian Health System audited its spending on employee medications to learn the scope of spread pricing. For the antibiotic amoxicillin, Meridian was billed $92.53 when an employee filled the prescription, but its PBM paid only $26.91 to the pharmacy to fill the same prescription. That amounted to a spread of $65.62 for only one prescription.

In another instance, Meridian was billed $26.87 for a prescription of azithromycin. The PBM paid the pharmacy $5.19 to dispense the prescription, creating a spread of $21.68. While the PBM continually promised savings, Meridian paid $1.3 million in unnecessary prescription benefits costs to this vendor due to the spread, Eban alleged.

Dramatic Generic Price Increases

But bigger drug cost problems may not be the PBM’s fault: generics can be the subject of dramatic inexplicable year-to-year price variations, which the plan might not be able escape. Hayes gave the example of tetracycline 500 mg capsules, which shot up in price 177-fold from 2013 to 2014.

The problem of selected generic drugs becoming wildly expensive for unknown reasons has drawn the attention of Members of Congress.

Sen. Bernie Sanders, I-Vt. and Sen. Elijah Cummings, D-Md., on Oct. 2 sent letters to 14 generic drug manufacturers asking why dramatic price increases had occurred in just the past few months for: Doxycycline Hyclate, an antibiotic; Pravastatin Sodium, a high cholesterol drug; Divalproex Sodium, a treatment for migraines; Albuterol Sulfate, a treatment for asthma; and several others. These drugs leapt in price five- to 50-fold in as little as six months.

Greater Plan Control

Plans can achieve savings by accepting fiduciary responsibility, Hayes told the IFEBP attendees; for example, by writing cost-savings drug management provisions into the plan document and managing drug spending in accord with that document. That way they can limit plan expenses to what’s reasonable and what can be defended. For example, many plans are finding savings by using more than three tiers of coverage, to steer utilization toward generics, or toward the most clinically appropriate brand-name medication.

A health plan that has accepted fiduciary responsibility may use tougher step-therapy rules by requiring a less expensive therapy be tried before authorizing an expensive one. In other example, plans may be able to apply coverage criteria for expensive therapies that authorize coverage at a later disease stage than the company’s PBM does.

Also, a plan may want to use a closed formulary under which it can laser out for non-covered drugs that suddenly become prohibitively expensive.

A plan may want to use a “new-to-market” exclusion that slaps a temporary moratorium on brand new therapies to allow plan committees to review them and to allow some price stability to emerge. This gives the plan time to seek out a distribution challenge, study the cost impact and seek out its own drug strategy. This could be a strategy for new specialty drugs.

If a plan takes more control, it can enact strict plan provisions against physician off-label use and then in detect such ineligible claims and preventing payment for them, she suggested.

But it is important for plans not to take drug cost-cutting in isolation, Hayes said. Limiting the cost of medications can trigger increased physician and hospital costs down the line. One study found that the “achievement” of reducing spending on outpatient drugs by 79 percent was offset by a 3-percent increase in physician and a 23-percent increase in hospital costs.

Fiduciary responsibility can cut both ways. Fiduciaries are expected to act on behalf of participants with the exclusive purpose of providing benefits to them. If plans accept ERISA fiduciary status, they might be obliged to cover medications that are expensive, and that might sometimes involve having to override a PBM exclusion, she noted. If invoking fiduciary authority to override PBM decisions goes only in one direction; that is, for plan cost savings and never for better clinical care for the patient, the plan could run into trouble down the road.

By Todd Leeuwenburgh

Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]

Thursday, November 6, 2014

We Need More Transparency on the Cost of Specialty Drugs

The economics principle “The more you concentrate your buying power, the better your pricing” applies in health care, too. That’s why health insurance companies can offer customers lower premiums by restricting the size of provider networks. They send more patients to fewer hospitals — and get a better deal per patient, passing on at least some of the savings to you.
Next up for restrictions: specialty drugs. These expensive medicines treat diseases, such as specific cancers or multiple sclerosis, that affect relatively small populations. That means you may not get the drug your doctor wants to prescribe — or if you do, it will cost you a lot more money.
Theoretically, there’s nothing wrong with this. If the choices are medically appropriate, the savings to the system should justify the restrictions. But that’s a big “if.” We don’t know how a payer decides to give one specialty medicine preference over another. The drug formulary is a giant black box.
If this opaque process yielded good decisions, you could stop reading now. But it doesn’t. Brian Bresnahan and colleagues have found that pharmacy and therapeutics (P&T) committees sometimes favor the wrong drugs. In effect, more cost-effective medicines may be ranked lower in a formulary while less cost-effective drugs earn better slots. Somewhere between 600 and 1,000 P&T committees are making these kinds of decisions today.
The Current Process
To understand how all of this works, you first have to see the payer’s point of view. The fastest-growing costs in health care today are for specialty drugs. Take Sovaldi, launched by Gilead Sciences in late 2013 as a treatment for hepatitis C virus (HCV) infection and recently superseded by Gilead’s newest drug, Harvoni.
Sovaldi represented a true medical breakthrough relative to previous HCV treatments — much shorter duration of therapy, dramatically reduced side effects, and very often a cure. But Sovaldi, Harvoni, and a raft of coming competitors also represent a staggering new economic reality. Sovaldi itself costs about $84,000. Harvoni costs $95,000 for 12 weeks of therapy (roughly equivalent to the cost of Sovaldi and the other drugs that must be taken with it), although Harvoni will cost $63,000 for patients who need only eight weeks of treatment.
In a July 2014 JAMA article, Troyen Brennan and William Shrank, respectively the chief medical and scientific officers at CVS Caremark, a major pharmacy benefit manager (PBM), estimated that with as many as 3 million eligible HCV patients in the U.S., “treatment of patients with HCV could add $200 to $300 per year to every insured American’s health insurance premium for each of the next 5 years.” Meanwhile, analysts’ predictions of total 2018 U.S. sales for Sovaldi, Harvoni, and their competitors cluster between $11 billion and $13 billion.
Sovaldi and Harvoni are just two examples of the explosion in spending on specialty drugs — 20% a year, according to the PBM Express Scripts. That is roughly four times the percentage rise in the cost of health care overall. Given current trends, specialty drugs will account for about half of the U.S. total drug bill within a few years.
That’s precisely why insurance companies and PBMs, largely at the behest of their employer customers, are narrowing their specialty-drug formularies. This practice encourages patients and physicians to choose from a more restricted list of options. And not all the choices are easy — a plan may no longer pay for, say, a rheumatoid arthritis medicine on which a patient is doing well, forcing her to self-experiment with the plan’s other (cheaper) preferred agents.
How to Crack Open the Box
Arguing that payers should not restrict drug formularies would be naive. As costs rise, there’s no other choice. But we contend that, as the stakes of these decisions grow, the transparency and the rigor of the decision-making process must increase proportionately. 
To illustrate the problem, let’s start with an example from October 2013, when Express Scripts decided to exclude 46 drugs from its formulary. Several press reports noted that the PBM wouldn’t disclose its rationale, other than to say that its independent P&T committee had found that the excluded drugs offered no additional value over that of existing, lower-cost drugs. To continue reading click here.
by Robert Galvin, MD and Roger Longman

Wednesday, October 29, 2014

Friction Between Health Plans, Pharma Grows Over Specialty Drugs

The war of words between managed care and pharmaceutical manufacturers, which began when Gilead set the price for its drug to treat the hepatitis C virus (HCV), has taken off in October with the reclassification of a trio of cancer drugs from Genentech.

Growth in the “specialty pharma” sector, where prices are rising much faster than drug prices generally, has drawn concern from payers and the umbrella group that represents them, while the trade group that represents drugmakers is pushing back against critics, saying that it faces challenges in bringing life-saving therapies to market.

All this is playing out against the backdrop of the Affordable Care Act (ACA), which professes to rein in the nation’s escalating healthcare costs, including drug prices. As the second year of open enrollment on the exchanges gets underway, a series of events in the healthcare sector have spilled into the public arena, just in time for the November 4 midterm elections:

  • America’s Health Insurance Plans (AHIP) took aim at the $1000-per-pill cost of Gilead’s Sovaldi, the breakthrough treatment for HCV as a symbol of the rising challenge of the specialty pharma sector, which AHIP says accounts for an “unsustainable” share of health plans. An AHIP issue brief from February 2014 stated that in 2012, specialty drugs accounted for 1% of all prescriptions but 25% of the drug costs.
  • On September 18, 2014, Genentech announced that 3 mainstay cancer therapies – Avastin, Herceptin, and Rituxan – would no longer be available to hospitals from wholesale distributors and would instead be sold through a select group of specialty distributors, increasing their costs. The change took effect October 1, 2014, giving the hospitals little time to absorb the change.
  • On October 5, 2014, leading oncologists took aim at pharmaceutical prices in a 60 Minutes segment in which one clinician said that, “High cancer drug prices are harming patients, because either you come up with the money, or you die.”

In recent days, the Pharmaceutical Research and Manufacturers of America, or PhRMA, has countered with its Access Better Coverage initiative, which is designed to guide consumers shopping for coverage on the exchanges as they select health plans based on what out-of-pocket expenses they would face for prescription drugs.

But the broader message of the campaign is to point out instances in which plans have assigned all patients with conditions such as HIV into higher-price drug tiers, which was the topic of a well-read editorial in The American Journal of Managed Care by Gerry Oster, PhD, and A. Mark Fendrick, MD.

by Mary K. Caffrey

Sunday, October 26, 2014

Pharmacy Carve-Out: 7 Benefits for Self-Funded or Fully Insured Employers

PBM programs typically function in two ways. They are either “carved in”, provided by the health insurance company or “carved out”, provided independent of insurance. Whether the pharmacy benefit plan is self-funded or fully insured, any employer with more than 100 active employees should consider and investigate a carve-out strategy for their pharmacy benefits.

A carved out program provides better cost control and transparency, technology and services, as well as information and reporting. Health insurers may bundle the two programs and subsidize some of the pricing from one service with that of another.

For companies with a carved in program, there may be concerns about changing to a carved out program due to a perception that additional time and resources will be needed, but I have seen that on a day to day basis, there is little difference in having a separate PBM program. The functions are the same.

Over the course of a year, there are separate review meetings for companies with carved out programs, but overall, the time spent should be roughly the same as meetings taking place with carved in providers.

From the employees point of view there is virtually no change besides possibly another card in their wallet. They will have continued access to the full range of services offered by a PBM. In fact, many carved in programs use third party PBM companies to provide the pharmacy services.

Believe it or not, as companies get through the open enrollment season for benefits, the planning cycle starts for the next year – in this case 2016. The first quarter of the year is the time for benefits teams to review contracts and benefits plans, including pharmacy benefit plans.

What are the Benefits of a Pharmacy Carve-out?

There are significant advantages to pursuing a carve-out strategy, both for the plan sponsor and plan participants. Among the advantages are the following:

1.  Better Contract Terms – Carved-in plans are based on a single, pre-determined contract that does not allow a plan sponsor or its advisor to negotiate non-pricing terms critical to managing cost trends. For example, carved-in Rx plans seldom have audit rights and, if they do, they are frequently toothless. Detailed clinical programs are also usually missing. Conversely, a carved-out PBM contract, if correctly negotiated by the plan sponsor or an advisor specializing in pharmacy benefit contracting, will clearly outline all of the important non-pricing terms.

2.  Carved-out Specialty Rx – A carved-out PBM also permits the plan sponsor to install a carved-out specialty pharmacy benefit. Because specialty pharmacy is the fastest growing and most expensive portion of any pharmacy benefit plan, carving-out specialty drugs provides all of the advantages listed above.

3.  Customized Clinical Programs – Better data management and detailed analytics enable clinical licensed pharmacists, whether at the PBM or within a specialized advisory firm, to recommend, implement, and manage customized clinical programs based on the plan sponsors unique population. Examples of this include opioid management, diabetes management, and oncology programs.

4.  Lower Pharmacy Costs – A carved-out PBM contract allows for aggressive price negotiations and more competitive Request For Proposals (RFPs). Separating the medical and prescription drug benefits enables a plan sponsor to compare pricing for both benefits on an apples-to-apples basis. A direct PBM contract will also include the critical terms that govern pricing, including discounts, rebates and soft dollar programs. In addition, administrative costs are not hidden within the healthcare benefits fee. Carved-in plans have increased fees and costs that reflect the health plan receiving compensation from their PBM arrangement.

Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]

5.  Improved Data Management – Stand-alone PBMs with carved-out plans and direct contracts with plan sponsors capture and report all claims elements, allowing for accurate modeling, forecasting, and strategic planning. Data feeds and FTP interfaces between the PBM and the medical claims administrator allow automated delivery of pharmacy benefit claims and integration with medical claims. Plan sponsors and advisors can use the combined analytics to track trends and make informed benefit decisions.

6.  More Detailed Analytics – The enhanced data management described above means more detailed reporting capabilities, more sophisticated analytical tools, and more accurate forecasting and modeling. All of these contribute to lower annual drug spend and better long-term planning.

7.  Transparency – A carved-in plan has little or no transparency for the cost of the prescription drugs, the size of the mark-up, the rebates earned by the health plan, the contract volume pricing concessions negotiated by the health plan, or other financial incentives, all of which drive up cost to the plan sponsor. The health plan administrator provides none of the details critical to lowering cost, managing risk, and creating better clinical outcomes.

Medical and prescription benefits are completely different. The core strength of health plans and medical carriers is managing discounts with hospital chains and building provider networks. These skills are not transferable to managing prescription drug benefits, which are very different and, in many ways, more complex and more dynamic.

Driven principally by specialty pharmaceuticals, pharmacy benefit costs are forecast to increase between 15 and 18% per year for the foreseeable future. By carving out pharmacy benefits, plan sponsors create the potential to save up to 50% per year on pharmacy benefits service costs.

Tuesday, October 21, 2014

Repackaging: A "Traditional" Pharmacy Benefit Manager's Black Box Tactic [Video]

Repackaging typically occurs when a company buys a large bottle of a prescription medication such as Lisinopril, and makes it into smaller bottle sizes. So, if a company buys a 1000 count bottle of Lisinopril and simply divides it into 10 bottles of 100, this is repackaging. 

The new bottle of 100 is given a new NDC or national drug code and a new price. The new price is at the discretion of the re-packager and most likely higher than the original price. Watch the video below for a detailed illustration.

video

An even bigger problem (as if the repackaging wasn’t enough) is that most drug pricing for consumer plans are based upon AWP minus a certain percentage. When drugs are purchased, especially through mail order, the payer will not know if the AWP used in the cost formula was derived from an AWP reporting service such as Medispan or newly created as a result of repackaging.

The best means to determine if a medication was repackaged is to compare the NDC from the resulting claim to the manufacturer or distributor NDC. Traditional PBMs will not share this information with you. Fiduciary PBMs such as TransparentRx, LLC, will.

Monday, October 20, 2014

Reference Pricing: Pharmacy Invoice Cost (ACTUAL) for Top Selling Generic and Brand Prescription Drugs

Why is this document important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to healthcare reform. 

The costs shared below are what our pharmacy actually pays; not AWP, MAC or WAC.  The bottom line; payers must have access to "reference pricing." Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders. 

Note: This document is updated weekly to reflect changing prices and new products.

How to Determine if Your Company [or Client] is Overpaying
Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month.

Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list.

Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement.  It's impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions.

Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our pharmacy cost then determine if a problem exists. When there is a 5% or more price differential (paid versus actual cost) we consider this a problem.

Multiple price differential discoveries means that your organization or client is likely overpaying. REPEAT these steps once per month.

-- Tip --

Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine if better pricing is available in the marketplace compared to what the client is currently receiving. 

When better pricing is discovered the contract language should stipulate the client be indemnified. Do not allow the PBM to limit the market check language to a similar size client, benefit design and/or drug utilization.  In this case, the market check language is effectually meaningless.


Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]

Thursday, October 16, 2014

National Health Expenditure Projections 2013-2023

Major Findings

  • Health spending is projected to grow at an average rate of 5.7 percent for 2013-2023, 1.1percentage points faster than expected average annual growth in the Gross DomesticProduct (GDP).
  • Health spending growth for 2013 is projected to have remained slow at 3.6 percent due tothe modest economic recovery, the impacts of sequestration and continued slow growth in the utilization of Medicare services, and continued increases in cost-sharing requirements for the privately insured.
  • Improving economic conditions, the Affordable Care Act (ACA) coverage expansions, and the aging of the population, drive faster projected growth in health spending in 2014 and beyond.
    • Expected growth for 2014 is 5.6 percent, as 9 million Americans are projected to gain health insurance coverage, predominantly through Medicaid or the Health Insurance Marketplaces.
    • Average annual projected growth of 6.0 percent per year is projected for 2015 through 2023, largely as a result of the continued implementation of the ACA coverage expansions, faster projected economic growth, and the aging of the population. While projected growth is faster compared to recent experience, it is still slower than the growth observed over the longer-term history.
    • The number of uninsured people is expected to decline from 45 million people in 2012 to 23 million people by 2023.
    • By 2023, health expenditures financed by federal, state, and local governments are projected to account for 48 percent of national health spending and to reach a total of $2.5 trillion; in 2012, such expenditures constituted 44 percent of national health spending and $1.2 trillion.
  • Health spending is projected to be 19.3 percent of GDP by 2023, up from 17.2 percent in 2012.
Major Findings by Payer

Medicare

  • Due to a deceleration in growth driven by sequestration and lower utilization across services, Medicare spending growth is projected to have slowed to 3.3 percent in 2013, down from 4.8 percent growth in 2012, and to have totaled $591.2 billion. 
  • Projected Medicare spending growth of 4.2 percent in 2014 reflects both an expected  increase in use and intensity of Medicare services, alongside slow increases in payment rates. For 2015, Medicare growth is projected to slow to 2.7 percent, mostly due to lower payments to Medicare Advantage plans.
  • For 2016 through 2023, projected Medicare spending growth is expected to rebound to 7.3 percent per year due to increased enrollment by the baby boomers, increased utilization of care, and higher payment rates driven by improved economic conditions, which increase growth in the cost of input goods and services used to treat Medicarepatients. These drivers in growth will be partially offset by slow growth in payment updates due to provisions in the Affordable Care Act and sequestration. 

Medicaid

  • Medicaid spending is anticipated to have grown 6.7 percent and to have reached $449.5 billion in 2013, driven by higher payments rates to primary care physicians called for in the Affordable Care Act, as well as actions by states that increased provider reimbursement rates and expanded benefits. 
  • Total Medicaid spending is projected to grow 12.8 percent in 2014 due to increased enrollment of nearly 8 million beneficiaries. Primarily driving the increase in enrollment are states that chose to expand coverage to adults up to 138 percent of the federal poverty level. 
  • As some states are expected to expand their Medicaid programs after 2014, an additional 8.5 million people are expected to enroll in the program by 2016. Medicaid spending is expected to grow by 6.7 percent in 2015, and 8.6 percent in 2016. For 2016 to 2023, Medicaid spending growth is projected to be 6.8 percent per year on average. 
Private Health Insurance

  • Spending for total private health insurance premiums ($947.5 billion) is projected to have grown by 3.3 percent in 2013, or about the same rate of growth as was observed for 2012. Premiums in 2013 are expected to grow slightly faster than benefits (3.0 percent) due to 6.0 percent growth in the net cost of private health insurance, an increase from 0.1 percent growth in 2012.
  • Private health insurance premium growth is projected to reach 6.8 percent in 2014 due to higher per enrollee spending and increased enrollment through Marketplace plans. 
  • Private health insurance spending growth is expected to remain somewhat elevated at 6.9 percent in 2015, primarily due to additional enrollment into health insurance plans. For 2016 through 2023, after the ACA-related enrollment shifts play out, the effects of improved economic conditions are expected to sustain average private health insurance spending growth of 5.4 percent per year.

Out-of-Pocket

  • In 2013, out-of-pocket spending is projected to have grown 3.2 percent, slightly slower than the growth rates in 2011 and 2012, and to have reached $338.6 billion. Relatively slow growth in out-of-pocket spending is due to low growth in utilization, and higher cost-sharing requirements for the insured, which tend to discourage people from using covered services.
  • Out-of-pocket spending growth is projected to decrease by 0.2 percent in 2014 as a result of the Affordable Care Act’s coverage expansions. 
  • While out-of-pocket spending growth is projected to accelerate after 2015, reaching a peak of 5.8 percent in 2020, the out-of-pocket share of health spending is projected to fall from 11.7 percent in 2013 to 9.9 percent by 2023.

Major Findings by Sector

Hospital

  • Total hospital spending is anticipated to have slowed to 4.1 percent in 2013, reaching $918.8 billion, compared with 4.9 percent growth in 2012. This would represent the fourth consecutive year that hospital spending growth has been under 5 percent after averaging 7.2 percent for 2001 through 2009. 
  • In 2014, hospital spending growth is projected to be 4.5 percent, which largely reflects greater use of hospital services associated with the coverage expansions from the Affordable Care Act. 
  • In 2015, hospital spending is projected to increase 5.1 percent due to the continued effects of the ACA insurance expansion combined with the effect of faster economic growth. For 2016 through 2023, continued population aging and the impacts of improved economic conditions are expected to result in projected average annual growth of 6.2 percent.

Physician and Clinical Services

  • Growth in spending on physician and clinical services (583.9 billion) is projected to have decelerated in 2013 to 3.3 percent, after growth of 4.6 percent in 2012 (and would mark the fifth consecutive year this rate would be below 5.0 percent). This trend is related to the slowest growth in physician prices since 2002, which is due in part to the sequester and procedural payment changes in Medicare.
  • In 2014, physician and clinical services spending growth is projected to be 5.9 percent. As many of the newly insured are anticipated to be generally younger, on average, compared to the current Medicaid and private insurance populations, they are expected to devote a relatively larger share of their medical spending to prescription drugs and physician and clinical services than to hospital care. 
  • For 2015, lower payments to Medicare Advantage plans, as well as expiration of temporary payment increases to Medicaid providers, is expected to slow growth to 3.8 percent for physician and clinical services. 
  • For 2016-2023 Medicare spending on physician and clinical services is projected to average 7.1 percent due to more favorable economic conditions and higher enrollment in private health insurance plans. 

Prescription Drugs

  • In 2013, prescription drug spending is projected to have grown 3.3 percent (reaching $272.1 billion), compared to 0.4 percent growth in 2012. The projected acceleration is due to a smaller descending impact on growth from patent expirations (many of which exerted significant downward pressure on growth in 2011 and 2012) and increased utilization of prescription drugs. 
  • Projected prescription drug spending growth is 6.8 percent for 2014, and 6.4 percent in 2015, driven by increases in the use of prescription drugs among people who are newly insured and those who move to more generous insurance plans as a result of the premium and cost-sharing subsidies offered by the Affordable Care Act.
  • Prescription drug spending is projected to average 5.4 percent for 2016 through 2019 and 6.0 percent for 2020-2023. Faster growth is projected for 2020-2023 due to improving economic conditions, an expected rising trend of expensive specialty drugs being purchased through retail channels, and anticipated changing clinical guidelines designed to encourage drug therapies at earlier stages of treatment. 
Major Findings by Sponsor

  • Health care spending sponsored (or financed) by federal, state, and local governments is projected to have grown 3.2 percent (to $1.3 trillion) in 2013. 
  • Reflecting growth trends in private health insurance and out-of-pocket spending, outlays by businesses, households, and other private sources are projected to have risen by 3.9 percent in 2013, compared to 4.6 percent in 2012, and to have reached $1.6 trillion in 2013. 
  • For 2014, health care financing is projected to shift from households towards the federal government due to features of the Affordable Care Act coverage expansions, such as the 100-percent initial federal matching rate for newly eligible Medicaid enrollees, and subsidies for Marketplace coverage. As a result, the federal government’s share of spending is projected to increase to 28 percent in 2014, from 26 percent in 2013.
  • The government-sponsored share of health spending is projected to increase and account for 48 percent of national health expenditures by 2023, largely driven by Medicaid coverage expansions, Marketplace plan premium and cost-sharing subsidies, and an increasing gap between dedicated Medicare financing and program outlays.
Source:  Centers for Medicare and Medicaid Services

Monday, October 13, 2014

Reference Pricing: Pharmacy Invoice Cost (ACTUAL) for Top Selling Generic and Brand Prescription Drugs

Why is this document important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to healthcare reform. 

The costs shared below are what our pharmacy actually pays; not AWP, MAC or WAC.  The bottom line; payers must have access to "reference pricing." Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders.


How to Determine if Your Company [or Client] is Overpaying
Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month.

Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list.

Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement.  It's impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions.

Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our pharmacy cost then determine if a problem exists. When there is a 5% or more price differential (paid versus actual cost) we consider this a problem.

Multiple price differential discoveries means that your organization or client is likely overpaying. REPEAT these steps once per month.

-- Tip --

Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine if better pricing is available in the marketplace compared to what the client is currently receiving. 

When better pricing is discovered the contract language should stipulate the client be indemnified. Do not allow the PBM to limit the market check language to a similar size client, benefit design and/or drug utilization.  In this case, the market check language is effectually meaningless.


Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]

Wednesday, October 8, 2014

Generic Drug Field Full of Pricing Traps

Foreword: The zero-spread full pass through pharmacy benefits manager (PBM) program you were promised may not be all that it appears. The only way to guarantee (or at least have grounds for indemnification) is to do business with a fiduciary PBM; one that contractually agrees to always put its clients' needs first. By the way, I predicted both the rising cost of generic drugs and increased number of drug tiers last year!

*********************************************************************************

A friend of mine, a diabetic, stumbled on to another booby trap in the pricing of generic drugs. In my last column I described the new two-tiered arrangements insurers are pushing on patients. You can choose a non-preferred generic and pay more, maybe a lot more, or a preferred generic and get a price break. That’s the same pricing scheme insurers use for the expensive brand-name drugs.

Rising costs are a direct result of demand
Consumer groups, doctors, and insurance carriers have encouraged patients to choose generics over the name brands as a way to help lower the nation’s healthcare tab. So for many years my friend has been using a generic drug called Gemfibrozil that diabetics often take to lower triglycerides and cholesterol.

It has worked for him. No nasty drug interactions. No nasty side effects. And the price has been low--$2.71 for 60 pills. In August the price more than doubled to $6.14. He was still OK with that.

He was not OK when he got a bill in September from Express Scripts, the pharmacy benefit manager for his Medigap carrier whose plan is offered by his former employer, the City of New York. (PBMs, as they’re called, manage the drug benefits for employers and insurers and supposedly help hold the line on prices.)

Express Scripts wrote his doctor without consulting my friend, the patient, suggesting that for reasons of “safety and efficacy,” he should switch his patient to a different drug, a generic called Fenofibric acid. His share of the cost would now be $156.70 for 90 pills. Fenofibric acid costs $1.74 per pill compared to Gemfibrozil’s 10 cents a pill resulting in an out-of-pocket cost increase of 1,640 percent.

Why the switch, my friend asked his doctor. The doctor pointed to the reasons given in the letter about an increased risk of skeletal muscle effects and said maybe it was advisable to try the new drug. He was, however, astounded by the price, but my friend said it was clear the doctor wasn’t going to fight the PBM.

My friend spoke to an official at New York City’s employee benefits office who said her office has never heard of a PBM recommending that a more expensive generic drug replace a cheaper one.

I rang up John Rother, former chief lobbyist for AARP and now head of a group called the National Coalition on Health Care. The Coalition is waging a campaign to educate the public about the exorbitant prices of drugs, particularly the Hepatitis C drug Sovaldi and other specialty drugs in the pipeline that will carry super high price tags.

“Generic drug prices have been rising steeply, and there doesn’t seem to be an explanation for it,” Rother told me. He said he could only guess that some generic drug makers are leaving the market and the ones remaining will have less competition and the power to increase market share and raise prices.

Maybe there are medical reasons my friend should make the switch, but so far his doctor hasn’t been persuasive. Has the PBM discovered new side effects for the drug he’s been taking? Who’s treating the patient---the doctor or the PBM? And how does this big price jump fit in with the PBM’s purported mission: to save money for insurers and employers? Was my friend caught in a tussle between the clinician and the bean counters? How does he know who’s right without doing extensive research himself?

Since individuals can’t negotiate prices with drug companies, and Congress has prohibited Medicare from negotiating prices when it passed the prescription drug benefit law in 2003, my friend says, “companies have carte blanche to rip people off. In situations like this no one ever talks straight, but someone is making a lot more money.” He’s trying to get back on Gemfibrozil or a similar generic that’s cheaper than the one the PBM suggested.

Rother looks at the big picture now coming into focus from the sharply rising prices of generics. “Four years after we passed what we thought was universal health coverage, you can’t get the medicines you need because of the prices. It’s tragic,” he says.

By Trudy Lieberman, Rural Health News Service

Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]

Monday, October 6, 2014

Reference Pricing: Pharmacy Invoice Cost (ACTUAL) for Top Selling Generic and Brand Prescription Drugs

Why is this document important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to healthcare reform. 

The costs shared below are what our pharmacy actually pays; not AWP, MAC or WAC.  The bottom line; payers must have access to "reference pricing." Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders.

How to Determine if Your Company [or Client] is Overpaying
Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month.

Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list.

Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement.  It's impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions.

Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our pharmacy cost then determine if a problem exists. When there is a 5% or more price differential (paid versus actual cost) we consider this a problem.

Multiple price differential discoveries means that your organization or client is likely overpaying. REPEAT these steps once per month.

-- Tip --

Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine if better pricing is available in the marketplace compared to what the client is currently receiving. 

When better pricing is discovered the contract language should stipulate the client be indemnified. Do not allow the PBM to limit the market check language to a similar size client, benefit design and/or drug utilization.  In this case, the market check language is effectually meaningless.


Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]