Thursday, July 12, 2018

IFEBP provides tips on managing specialty drugs

The retail price of specialty drugs increased by almost 10 percent in 2015, following nine years of increases, according a study from the AARP. In the report, No Magic Pill to Cure Specialty Drug Costs (But Some Preventive Measures), the International Foundation of Employee Benefit Plans (IFEBP) provided tips for employers to help manage the cost of specialty medications.

The IFEBP provided the following tips:

1)  Change where specialty drugs are administered (called site of care). Having the patient go to a clinic or the doctor’s office increases costs. Could the drug be self-administered at home? Or, if someone must administer the drug to the patient, could it be done via a less costly home care service?

2)  Review the pharmacy benefit manager (PBM) contract. Look for inconsistent definitions. Ensure the PBM passes all rebates on to the employer plan.

3)  Refer participants to patient and copayment assistance programs to receive financial help.

[Read More]

Thursday, July 5, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 226)

This document is updated weekly, but why is it 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 health care reform.

The costs shared here are what the pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to actual acquisition costs or AAC. 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.

Tuesday, July 3, 2018

Clawbacks: Settling the score with non-fiduciary pharmacy benefit managers

Click to Learn More
This billing practice is known as a “clawback” and you may have no idea it’s happening to your employees or how it impacts your pharmacy costs. Furthermore, pharmacists aren't allowed to tell patients, under a gag order, that restricts pharmacists from telling patients they are being
overcharged.

These clawback monies are a contributing factor to the unchecked service fees non-fiduciary PBMs rely upon to cover overhead.

Tyrone's Commentary:

It’s all about the contract. 

1) Demand radical transparency
2) Negotiate financial and nonfinancial contracting terms for both direct and indirect revenues
3) Get educated

[Read More]

Thursday, June 28, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 225)

This document is updated weekly, but why is it 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 health care reform.

The costs shared here are what the pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to actual acquisition costs or AAC. 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.

Tuesday, June 26, 2018

What is a fair share? Pharmacy middlemen made $223.7M from Ohio Medicaid

The middlemen, called pharmacy benefits managers, are under scrutiny for how transparent they are in how the public money gets spent. The new report shows the companies retained $223.7 million last year of the money they billed Medicaid.

CVS Caremark, with the same parent company as CVS retail pharmacies, manages pharmacy benefits for four of the five Medicaid managed care companies. Last year it kept 8.7 percent or the payments it received, or $197.3 million. OptumRx does work for the other insurer and kept 9.4 percent, or $26.4 million.

Tyrone's Commentary:

Finally, someone is tackling a critical issue that too often gets tabled. I've been trying to bring PBM service fees (watch video below) to the mainstream for six years! The one question I have is why are public sector managers leading the charge?

6-Minute Video: Click to Learn More
I don't know the answer to that question but I do know the public sector is better at managing pharmacy costs than are commercial payers and that my loyal readers is a problem. Worst case scenario, it may very well be a dereliction of fiduciary duty by CFOs and HR Execs.

Greg Moody, the director of the Ohio Department of Health Transformation, which oversees Ohio Medicaid, said Ohio needs more information before it determines what is a fair share for the pharmacy benefit managers.

“At this stage we’re not saying that’s too high or too low,” Moody said. “What we’re saying is this is information we’ve never had before. And now the state, the managed care plans, the pharmacies have more information to make their argument and determine if that number is too high or too low or what should happen next.”

[Read More]

Monday, June 25, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 224)

This document is updated weekly, but why is it 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 health care reform.

The costs shared here are what the pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to actual acquisition costs or AAC. 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.

Wednesday, June 20, 2018

Dereliction of Fiduciary Duties by CFOs and HR Execs Triggering Department of Labor Investigations

Click to Learn More
The first shots across the bow have been fired highlighting how benefits leaders need to pay as close attention to health benefits as they have been paying to retirement plans. The most recent lawsuits name the HR leaders in the companies involved (GAP and CB&I) as defendants since they are listed as the plan administrator (sometimes CFOs are the plan administrators).

Tyrone's Commentary:

It's been my experience that most brokers and consultants are well-schooled in medical benefits but have not quite yet reached that same level of proficiency in the pharmacy benefits arena. Furthermore, there exists an expectation gap between what HR Execs and CFOs believe their brokers to know and what they actually know [do] about pharmacy benefits management. This is a good time to close that gap and get ahead of the problem before it bites you in the you know what. 

It’s clear that there is going to be the increased scrutiny for health benefits that has been commonplace for retirement benefits. For example, you can Google “ERISA class action” to find the many cases surrounding retirement benefits going after plan administrators for failing in their fiduciary duties. Similar cases in health care could have as far-reaching implications as Obamacare in driving employers to health benefits that deliver value.

[Read More]

Thursday, June 14, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 223)

This document is updated weekly, but why is it 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 health care reform.

The costs shared here are what the pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to actual acquisition costs or AAC. 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.

Wednesday, June 13, 2018

3 strategies for reducing pharmacy costs

As more high-priced drugs enter the market, employers must keep a closer eye on it as part of an overall cost-savings strategy. For employers and brokers trying to determine how to decrease pharmacy costs for their organization and clients, here are three distinct components to consider.
Click to Learn More

EDUCATION

Smart companies may work on their own to educate themselves on the space, but many are partnering with PBMs or brokers to manage health plans and educate employees. This process is helping employers educate themselves on best practices to lower pharma costs, like steerage towards generic prescriptions and rebate negotiations, and use insights from partners to more effectively drive action with analytic reports.

Tyrone's Commentary:

I read a bunch of articles and this is the first one I've come across which directly addresses education, in the PBM space, as a means for employers to reduce pharmacy costs. Kudos to BenefitsPro for putting employers first.

However, the health system is complex. Employees aren’t going to necessarily understand the relationship with PBMs, so it’s up to the employer to teach their workplace to explore and ask about more affordable health care option.

[Read More]

Sunday, June 10, 2018

State Rx law cut down on appeal; benefits manager group prevails in federal panel ruling

Click to Learn More
A federal appeals court unanimously ruled Friday in favor of a pharmacy trade association's challenge to an Arkansas law governing how pharmacists are reimbursed for generic drugs.

At issue is Act 900 of 2015, a law that regulates pharmacy benefits managers, the entities that verify benefits and handle transactions among pharmacies, insurers and patients. CVS Caremark and Express Scripts are two of the largest benefits managers.

Pharmacies acquire drugs from wholesalers. Then, the patient buys the drug from the pharmacy, often at a lower cost because health plans cover part of the price. Benefits managers, the intermediary group, are responsible for reimbursing the costs of those generic drugs. They create a "maximum allowable cost" list that sets those rates.

Tyrone's Commentary:

Why do we continue to spin our wheels looking to legislation to fix the problem? In the PBM space, applied knowledge or learning that is used in various situations and contexts is faster and more cost-effective!

Act 900 prevents benefit managers from paying affiliated drugstores more than they pay other pharmacies for the same prescription. It also bans them from paying pharmacies a lower price than the wholesale cost of a drug, if the pharmacy takes measures to appeal that discrepancy.

[Read More]

Thursday, June 7, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 222)

This document is updated weekly, but why is it 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 health care reform.

The costs shared here are what the pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to actual acquisition costs or AAC. 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.

Wednesday, June 6, 2018

Mergers between health insurers and pharmacy benefit managers could be bad for your health

Click to Learn More
Pharmacy benefit managers (PBMs) buy drugs from manufacturers, distribute them to patients, and manage drug benefits for insurers and employers. Once an obscure segment of the health care financing landscape, pharmacy benefit managers have become industrial behemoths with revenues and profits that have outstripped those of the pharmaceutical companies that develop the drugs they distribute.

Tyrone's commentary:

If integrating the medical and pharmacy benefit requires that you relinquish flexibility and cost controls, the disadvantages of integration far outweigh the advantages. Disadvantages may include:
  • Plan members may pay U&C (usual and customary) prices, which are higher than discounted prices
  • Formulary and rebate arrangements may not be available or are significantly limited
  • Plan sponsors lack authority and flexibility and are typically unable to adjudicate plan limitations, plan exclusions, enforce generic dispensing mandates or validate appropriate drug pricing
There’s already a lack of transparency when it comes to drug prices and employers may have even less access to critical information if the insurer and the pharmacy benefit manager are the same entity. It’s going to be more difficult to get behind the curtain.

As intermediaries, non-fiduciary PBM companies profit twice on each transaction: They get fees from insurers and employers while obtaining rebates from manufacturers that are entirely hidden from public view. Across the industry, payments from pharmaceutical manufacturers to intermediaries now exceed $100 billion per year.

[Read More]

Monday, June 4, 2018

"Don't Miss" Webinar: How to Slash PBM Service Costs, up to 50%, Without Changing Vendors or Benefit Levels

How many businesses do you know want to cut their revenues in half? That's why traditional pharmacy benefit managers don't offer radical transparency and instead opt for hidden cash flow opportunities such as rebate masking. Want to learn more?

Here is what some participants have said about the webinar.

"Thank you Tyrone. Nice job, good information." David Stoots, AVP

"Thank you! Awesome presentation." Mallory Nelson, PharmD

"Thank you Tyrone for this informative meeting." David Wachtel, VP

"...Great presentation! I had our two partners on the presentation as well. Very informative." Nolan Waterfall, Agent/Benefits Specialist

A snapshot of what you will learn during this 30 minute webinar:
  • Hidden cash flows in the PBM Industry such as formulary steering, rebate masking and differential pricing 
  • How to calculate cost of pharmacy benefit manager services or CPBMS
  • Specialty pharmacy cost-containment strategies
  • The financial impact of actual acquisition cost (AAC) vs. maximum allowable cost (MAC)
  • Why mail-order and preferred pharmacy networks may not be the great deal you were sold

Sincerely,
TransparentRx
Tyrone D. Squires, MBA  
3960 Howard Hughes Pkwy., Suite 500  
Las Vegas, NV 89169  
866-499-1940 Ext. 201


P.S.  Yes, it's recorded. I know you're busy ... so register now and we'll send you the link to the session recording as soon as it's ready.

Friday, June 1, 2018

Why CVS Loves ObamaCare

Click to Learn More
Big business feasts on big government, and ObamaCare has been a bonanza for companies that have figured out how to exploit it. Witness how CVS Health is dining out on Ohio’s Medicaid expansion.

In addition to retail pharmacies, CVS operates a pharmaceutical benefit manager (PBM) that acts as a middleman between insurers, pharmacies and drug manufacturers. PBMs decide which drugs are listed on a formulary, how much pharmacies are reimbursed and how much insurers pay.

Ohio contracts with five managed-care organizations (MCOs) to administer Medicaid benefits, four of which outsource their drug benefits management to CVS Caremark, the CVS PBM. The state uses drug claims data to set its annual drug budget. So if claims increase, the state will allocate more Medicaid funds for drugs the following year.

Yet CVS appears to be billing the state for far more than what it is paying pharmacies, driving up taxpayer costs. CVS’s actual drug payments aren’t transparent to the state or MCOs.

[Read More]

Thursday, May 31, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 221)

This document is updated weekly, but why is it 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 health care reform.

The costs shared here are what the pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to actual acquisition costs or AAC. 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.

Tuesday, May 29, 2018

Amgen, AbbVie 'ahead of the crowd' in fighting payers' latest assault on copay coupons

Copay Coupon Sample
Copay coupons save patients money and help drugmakers steer scripts toward newer products or older ones facing new rivals. But because pharma does the steering, often toward drugs that actually cost more, payers hate them.

That is the copay coupon triangle, and there it has stood for years. But now, more than 40% of scripts for specialty drugs are paid for with those coupons—and the coupon battle is getting hotter than ever, with payers cracking down anew and pharma finding creative ways to thwart them.

The payers' new weapon of choice is the "copay accumulator," which prevents patients from applying copay coupons to their deductibles—and that, in turn, makes the drugs covered by those coupons less attractive. They've already taken a bite out of sales for some key products, pharma executives said during first-quarter earnings calls.

Thursday, May 24, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 220)

This document is updated weekly, but why is it 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 health care reform.

The costs shared here are what the pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to actual acquisition costs or AAC. 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.

Wednesday, May 23, 2018

Trump’s Drug Blueprint Could Alter PBM Contracting

Click to Learn More
With much fanfare, President Donald Trump's administration recently released a 44-page blueprint for executive action on drug pricing titled American Patients First. The blueprint proposes steps to end drug manufacturers' "gaming" of the regulatory process and to create incentives for pharmaceutical companies to lower list prices. The proposals regarding pharmacy benefit manager (PBM) firms, in particular, could affect drug costs covered by employer-sponsored group health plans.

The blueprint, however, also asks whether PBMs should be obligated to act solely in the interest of those for whom they manage drug benefits. If PBMs were identified as plan fiduciaries, they would be accountable for negotiating in the best interest of the plan and its members. This could certainly change the dynamics of current PBM relationships and, if adopted, keep PBMs from accepting certain types of payments from manufacturers that favor coverage of higher-cost drugs.

Tyrone's Commentary:

For all intents and purposes, there are only two types of PBM business models; non-fiduciary and fiduciary. Don't be fooled by labels such as pass-through, transparent, limited fiduciary (a new one) or others. I'm often asked what's the difference between a transparent and fiduciary PBM. Here is the big difference. A fiduciary PBM is required to act in its clients' best interest first for every action it takes on behalf of that client. In other words, the fiduciary PBM is contractually obligated to contain its clients cost. Any other PBM model regardless of what they tell you is not contractually obligated to contain costs. They are intentionally trying to avoid this responsibility so don't let them off the hook!

[Read More]

Friday, May 18, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 219)

This document is updated weekly, but why is it 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 health care reform.

The costs shared here are what the pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to actual acquisition costs or AAC. 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.

Tuesday, May 15, 2018

Appellate court kills Optum's $6.7B pharmacy benefits management contract; orders rebid

Click to Learn More
An appellate court has determined OptumRx's bid did not conform to the bid solicitation, because it included language reserving the right to modify the financial terms of the deal to protect its profit if the state made changes to the plan design.

"Optum's additional language ... permitted it to 'hedge' its bid, thereby reducing its financial risk from adverse plan design changes," the court said. "That set it apart from the other bidders who agreed to be bound by all of the terms of the bid solicitation."

Tyrone's Commentary:

I here it all the time from purchasers of PBM services; control the formulary, go for low net cost, not high rebates, work with a transparent PBM, or make sure the consulting firm isn't being comped. Everyone knows these things are important, but the execution is usually poor. Furthermore, if the self-insured employer and its consultant aren't informed or highly sophisticated it can lead to bad contract language that isn't consistent with bid responses or permits the PBM to modify terms during the contract's life, for instance. There are three parts to being an adept steward of a pharmacy benefit and they are not mutually exclusive. In other words, if you're poor in any one of these areas it will hurt you in the other two.

1) Education. If only I had a nickle every time a consultant or HR executive said I don't need any PBM education. That's like LeBron James saying I don't need to practice playing basketball. He's the best in the world yet he still studies the game more than any other player! You may attend a webinar or two, read a blog post or chat with peers and I can tell you it still isn't enough to beat non-fiduciary PBMs at their own game. Invest more time and money into becoming a better steward of pharmacy benefits. Incrementalism in this area will not be rewarded. The best proponent of transparency is informed and sophisticated purchasers of PBM services.

2) Procurement. Means the action of obtaining or procuring something. When obtaining PBM services, ideally it involves a reverse auction. The state of New Jersey ran a reverse auction but somehow Optum's bid still squeeked through. My guess is that human interference got in the way, as it often does, with the real bid winner or the reverse auction was inherently flawed. Because one takes action on a problem doesn't guarantee an optimal outcome. You can swing (act) at a 95 mph fastball but will miss (outcome) 99 out of a 100 times unless of course you're a well-trained professional and student of the game. There are a lot of companies and consultants that procure PBM services who are missing a lot! One problem is a lack of accountability unlike standing in the batters box alone. It would be nice if self-insured employers had a stopgap like an appellate court to fall back on. Oh wait they do and they're called benefits consultants.  
  
3) Vigorous Oversight. PBM performance should be monitored on an ongoing basis far beyond standard reports. The types of routine monitoring activities performed by the plan sponsor can vary based on past performance with the PBM or the nature of the services performed. The type and frequency of monitoring should be documented in the contract before it is executed. The plan sponsor should establish key performance metrics designed to measure PBM services. The PBM oversight program must also define what happens if the vendor’s performance is below the plan sponsor’s performance expectations. When noncompliant performance occurs, the plan sponsor should request a formal action plan defining specific activities to ensure performance meets the defined expectations. 

The state, meanwhile, argued Optum's language was meaningless and didn't affect the outcome of the auction. The three-person court invalidated the contract, saying its size, complexity and potential savings for the public aren't a shield from this type of review.

"No savings can justify the impairment to the integrity of the bidding process caused by an irregular proceeding, the court said.

[Read More]

Monday, May 14, 2018

From $14000 to $8000 Overnight with Almost No Restrictions; Cholesterol Drug has Potential to Break Self-Insured Employers' Bank

Amgen’s Repatha and Sanofi and Regeneron’s Praluent were approved in 2015 with blockbuster expectations. But the number of patients with high cholesterol and the $14,000 a year price tag of the drugs prompted heavy restrictions from PBMs.

In an attempt to juice sales, Sanofi and Regeneron substantially cut their drug’s net price for Express Scripts so it would reduce those restrictions. Back-slapping followed. But this is just a louder and bigger version of something that happens all of the time: an exchange of a bigger rebate for more favorable coverage.

Tyrone's Commentary:

At first glance the drop in price appears to be a positive move and it could very well turn out that way. However, self-funded employers have to keep a keen eye on utilization. Express Scripts will remove almost all restrictions on the medicine and make it cheaper for patients, for instance. Plan sponsors need to understand the manufacturer-side revenue ESI is generating for itself and its affect on final plan cost. Furthermore, consider implementing your own step therapy or PA processes. Robust oversight on PBM performance is standing operating procedure, but especially important for expensive medications.

If demand increases, Express Scripts benefits from a handsome rebate, and rising drug costs will largely flow through to clients. The list price is staying the same, and the majority of consumers will still be exposed. A few more patients will get Praluent, which is a genuinely good thing. And a pantomime of a dialogue about lower list prices is better than nothing. But at the end of the day, nothing really changes.

[Read More]

Thursday, May 10, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 218)

This document is updated weekly, but why is it 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 health care reform.

The costs shared here are what the pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to actual acquisition costs or AAC. 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.

Monday, May 7, 2018

Longtime chief of pharmacy benefit manager trade group to step down

Click to Learn More
Mark Merritt, president and chief executive officer of the Pharmaceutical Care Management Association, will step aside at the end of the year, after 15 years on the job, the trade group announced Monday morning. The news of Merritt's departure comes as pharmacy benefit managers (PBM), which PCMA represents, feel increasing pressure from the government and private industry alike.

1) Government pressure: Health and Human Services Secretary Alex Azar and Food and Drug Administration Commissioner Scott Gottlieb, MD, have each delivered incisive speeches with strong words directed at health plans and PBMs, criticizing a lack of transparency around their drug pricing and rebating contracts.

Tyrone's Commentary:  The winds of change have begun to blow.

2) Industry pressure: While PBMs are pushed by the government on one front, they're fighting a second front with private industry, enduring criticism from the pharmaceutical industry and a series of major mergers with insurers. St. Louis–based insurer Cigna announced plans in March to buy Express Scripts for about $52 billion, after CVS Health announced plans in December to buy insurer Aetna.

Thursday, May 3, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 217)

This document is updated weekly, but why is it 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 health care reform.

The costs shared here are what the pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to actual acquisition costs or AAC. 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.

Wednesday, May 2, 2018

ESI Reachs Deal on Struggling Cholesterol Drug with a List Price Over $8000

Image result for praluent copay cardDrugmakers Regeneron and Sanofi are cutting the price they charge pharmacy benefit manager Express Scripts for their cholesterol medicine, Praluent. In return, Express Scripts will remove almost all restrictions on the medicine, and make it cheaper for patients. In theory, that should mean a sales boost.

“I really hope this works because otherwise it's a bad message for everyone going forward,” says Steve Miller, Express Scripts’ chief medical officer. Why? Miller says that Praluent was hurt by a high price (list: $14,000 a year), and a lack of proof that it helped patients. But now, Miller says, things have changed.

Tuesday, May 1, 2018

"Don't Miss" Webinar: How to Slash PBM Service Costs, up to 50%, Without Changing Vendors or Benefit Levels

How many businesses do you know want to cut their revenues in half? That's why traditional pharmacy benefit managers don't offer radical transparency and instead opt for hidden cash flow opportunities such as rebate masking. Want to learn more?

Here is what some participants have said about the webinar.

"Thank you Tyrone. Nice job, good information." David Stoots, AVP

"Thank you! Awesome presentation." Mallory Nelson, PharmD

"Thank you Tyrone for this informative meeting." David Wachtel, VP

"...Great presentation! I had our two partners on the presentation as well. Very informative." Nolan Waterfall, Agent/Benefits Specialist

A snapshot of what you will learn during this 30 minute webinar:
  • Hidden cash flows in the PBM Industry such as formulary steering, rebate masking and differential pricing 
  • How to calculate cost of pharmacy benefit manager services or CPBMS
  • Specialty pharmacy cost-containment strategies
  • The financial impact of actual acquisition cost (AAC) vs. maximum allowable cost (MAC)
  • Why mail-order and preferred pharmacy networks may not be the great deal you were sold

Sincerely,
TransparentRx
Tyrone D. Squires, MBA  
3960 Howard Hughes Pkwy., Suite 500  
Las Vegas, NV 89169  
866-499-1940 Ext. 201


P.S.  Yes, it's recorded. I know you're busy ... so register now and we'll send you the link to the session recording as soon as it's ready.

Monday, April 30, 2018

Therapeutic Interchange: How It Could Affect Patients and Plan Sponsors

Earlier this month CVS Health stated that it is using various tools to help keep the inflationary cost of medication down to 0.2%. One of their methodologies that is mentioned at face value sounds rather benign, but according to Jon Roberts, executive vice president and chief operating officer, CVS Health.

“The lower cost growth was due in part to utilizing low-cost generic drugs, which were dispensed to 86% of pharmacy benefit management (PBM) clients.” In other words, 17 out of 20 patients were moved to generics. The term “therapeutic alternatives” means that CVS will be (somehow) getting patients to use a less expensive medication within a therapeutic category.
Source:  http://www.amcp.org

Tyrone's Commentary:

The author seems to miss at least part of the point. It's not just CVS Health who benefits from lower cost therapeutic alternatives; plan sponsors and patients may also benefit. He points out an extreme case and that's exactly what it is - extreme! If you don't care for CVS Health write that but don't deter patients from medications with equal efficacy yet lower cost. The AMCP agrees so I think I'll go with them. I do, however, agree plan sponsors have a responsibility to keep PBMs honest in any therapeutic substitution program.

To use an extreme example of how this could play out: let’s take blood thinners, within that class are “new oral anticoagulants” which includes Paradaxa, Xarelto, Eliquis. These medications each costs several hundred dollars per month. The “old” generic anti-coagulant is Warfarin which typically costs a patient as little as $4.00/month.

[Read More]

Thursday, April 26, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 216)

This document is updated weekly, but why is it 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 health care reform.

The costs shared here are what the pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to actual acquisition costs or AAC. 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.

Wednesday, April 25, 2018

The role of PBMs in the drug supply chain — and why it matters to employers

Most employers don’t understand how PBMs make money and what role they play in the drug supply chain. The fact is these “middlemen” can drive up pharmacy costs. Historically, PBMs have two main goals:

1. Negotiate drug prices in an effort to keep costs low for consumers and employers.

2. Favor the most effective drug where there are similar drugs treating the same condition.

But PBMs also have a third goal: to make money for their owners and shareholders. Arguably this goal overrides the other two. Many industry watchers — and members of the public — are wondering if PBMs provide much value other than skimming as much profit from the drug supply chain as possible.

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Thursday, April 19, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 215)

This document is updated weekly, but why is it 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 health care reform.

The costs shared here are what the pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to actual acquisition costs or AAC. 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.

Tuesday, April 17, 2018

Amazon About-Face On Drug Sales Not Surprising To Walgreens And CVS

News Amazon is backing away from an effort to sell drugs to hospitals doesn't come as a surprise to retail drugstore chains Walgreens Boots Alliance, CVS Health and distributors in the specialty pharmacy business.

CNBC reported Monday that the online retailer Amazon has “shelved a plan to sell drugs to hospitals” citing “complexities around selling in bulk to large hospitals and building a logistics network to handle pharma delivery.”

Tyrone's Commentary:

Amazon is bailing on selling prescription drugs due to complexities associated with the drug supply chain? I don't know if it's true, but the statement illustrates just how complex the U.S. pharmacy reimbursement and distribution system is for even the smartest companies. Amazon bails and you think you can manage pharmacy benefits efficiently by reading a blog post or watching a webinar or two? Don't kid yourself. 

But it’s not like CVS and Walgreens didn’t warn of the complexities of getting into the business of selling and processing prescription drugs, particularly specialty prescriptions shipped to hospitals and clinics.  “There are many barriers to entry when you’re looking at pharmacy,” CVS CEO Larry Merlo said in August of last year during a call with analysts.

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Monday, April 16, 2018

The Price of Non-Optimized Medication Therapy

Source:  Impact of medication adherence on
hospitalization risk and healthcare cost
Although rising prescription drug prices cause a financial burden, the cost often extends beyond the number that patients see on their bill, according to a recent analysis published in the Annals of Pharmacotherapy. When medication regimens are not appropriately optimized for the patient, the consequences can carry a hefty price tag.

According to the analysis, death and illness resulting from non-optimized medication therapy costs $528.4 billion annually, which is equivalent to 16% of total US health care expenditures in 2016. As the most readily available access point for most patients, pharmacists can play a key role in ensuring that medication therapies are optimized to help produce the best outcomes at the lowest cost.

Tyrone's Commentary:

No plan design is complete without a comprehensive medication adherence program. Key components of an employer plan to improve medication adherence include: 
  • Employee coaching and support teams 
  • Financial incentives to encourage medication adherence
  • Ensuring that the most appropriate medications are prescribed
  • Prescription management to avoid interactions and other dangers
The study was led by Jonathan Watanabe, PharmD, PhD, associate professor of clinical pharmacy in the Skaggs School of Pharmacy, with Jan Hirsch, PhD, professor of clinical pharmacy and chair of the Division of Clinical Pharmacy at Skaggs School of Pharmacy, and Terry McInnis, MD, of Laboratory Corporation of America and the Get the Medications Right Institute.

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Thursday, April 12, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 214)

This document is updated weekly, but why is it 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 health care reform.

The costs shared here are what the pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to actual acquisition costs or AAC. 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.

Tuesday, April 10, 2018

Two Generic Medications Become One Cash Cow Drug

Source:  Consumer Reports
For at least the past three years, Todd Smith and Benjamin Bove have crisscrossed the U.S., offering a sure-fire fix for struggling pharmaceutical companies. And wherever they go, the price of prescription drugs tends to skyrocket.

Their strategy is simple and, they say, good for patients: Thwart efforts by health plans to block access to drugs - and serve up what Smith calls their "special sauce" to get those meds into the hands of customers who need them.

The main ingredients include copays that are often zero, even for pricey drugs. Smith, 48, and Bove, 40, also offer the use of so-called specialty pharmacies - one of which they previously owned - to make it hassle-free for doctors and more affordable for patients. Yet critics point out that, over time, everyone might end up paying the price in the form of higher premiums. 

"It's totally a wrong way to frame the issue to say it's free to the patient," said Stephen Schondelmeyer, a professor of pharmaceutical economics at the University of Minnesota. "It's ripping people off."

Tyrone's commentary:

Implement a PBM oversight plan. PBM performance should be monitored on an ongoing basis with a formal business review no less than annually. The types of routine monitoring activities performed by the plan sponsor can vary based on past performance with the PBM or the nature of the services performed. The type and frequency of monitoring should be documented in the contract before it is executed.

The plan sponsor should establish key performance metrics designed to measure the PBM's services. For example, if the plan sponsor delegates call center operations to a PBM, then the performance metrics should include, at a minimum, hold time, average speed of answer and abandoned rate.

The PBM oversight program must also define what happens if the vendor’s performance is below the plan sponsor’s performance expectations. When noncompliant performance occurs, the plan sponsor should request a formal action plan defining specific activities to ensure performance meets the defined expectations. Depending upon the severity of performance, the plan sponsor should consider increasing monitoring and audit activities of the PBM.


If nothing else, Smith and Bove's business strategy illustrates a drug-pricing ecosystem that many agree is deeply flawed. President Donald Trump has accused drug companies of "getting away with murder," and his Health and Human Services Secretary, Alex Azar, has vowed to bring drug prices down. Yet the system is averse to change because so many of its key players continue to profit from its complexity and lack of transparency. Patients, meanwhile, are faced with fewer choices and higher deductibles and insurance premiums.

"These sophisticated traps are designed to pay off certain members of the supply chain in a way that exploits the employer, the insurance company and the consumer," said Michael Rea, chief executive officer of Rx Savings Solutions, which has an app that allows patients to find lower drug costs.

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