Friday, December 28, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 251)

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.

Thursday, December 27, 2018

Are Biosimilars the Future of Specialty Pharmacy?

Although there are several different types of biological products, which the FDA notes includes proteins, monoclonal antibodies, and vaccines with little in common. For example, biologic drugs are large molecules typically manufactured from living cells and, therefore, are extremely difficult to produce or reproduce.

In fact, there can be variations of acceptable range within the same manufacturing process because biologics are processed using living cell-based technology and the make of these agents is not easily identifiable.

For this reason, they are also highly sensitive to storage and handling processes and typically have a shorter shelf life than your average oral medications. So, why research, develop, and ultimately manufacturer such complex, sometimes costly medications you might ask?

Tyrone's Commentary:

We've seen this movie before, haven't we? Much like small molecule generic equivalents, biosimilars are a big threat to biologic market share. It just takes time.

Source: Generic Pharmaceutical Association annual savings and access report
Because they are able to effectively treat a variety of medical conditions that previously had limited to no other treatments available, thereby changing the lives of patients with conditions such as rheumatoid arthritis, cancer, and anemia, just to name a few.

[Read More]

Thursday, December 20, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 250)

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, December 18, 2018

Pennsylvania's Auditor General Demands PBM Contracting Transparency

Pennsylvania Auditor General, Eugene Depasquale, released a report discussing the role of pharmacy benefit managers (PBMs). The report, “Bringing Transparency and Accountability to Drug Pricing,” reviews PBM pricing practices with a critical eye.

If your pharmacy benefits management process doesn't
resemble the Auditor General's, blow it up. Here's how!
The Auditor General makes ten recommendations he believes will improve PBM pricing transparency, stabilize reimbursements to pharmacies, and ultimately lower the cost of prescription drugs for Pennsylvania residents.

1) To ensure taxpayer dollars are being handled effectively and efficiently, the general assembly should immediately pass legislation allowing the state to perform a full-scale annual review or audit of subcontracts with pharmacy benefit managers.

2) To better control costs, Pennsylvania DHS should consider directly managing its Medicaid prescription drug benefits instead of contracting with managed care organizations to do so.

3) The general assembly should pass legislation that increases transparency into PBM pricing practices.

4) So the state pays only for services PBMs render, the general assembly should pass legislation requiring a flat-fee pricing model for compensating PBMs.

5) Pennsylvania’s Department of Human Services should add “good steward” language to all Medicaid-related contracts.

Hmmm...looks like someone has been reading this blog. Get the full Auditor General's report here.

Thursday, December 13, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 249)

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.

Sunday, December 9, 2018

Ninety-Two Percent of Self-Insured Companies Lack a Formalized Pharmacy Benefits Management Process

Image result for no plan
Click Here To Get Your Plan
This one is the proverbial head-scratcher. Nine out of ten self-insured companies do not have a formalized pharmacy benefits management process. The results from our phone poll were startling, to say the least. During Q1-Q3 2018, I asked the TransparentRx sales staff to pose a question to small, medium and large self-insured employers.

In the qualification stage of our sales process, we asked employers, "do you have a written plan to procure, monitor and evaluate your pharmacy benefits management service?" Of the 1017 self-insured employers who responded, here is what they shared with us.

For the process to be considered "formalized" each employer had to have a written plan. If the employer did not have a written plan we considered them not to have a formalized process. We could've easily stopped there as 81% of employers did not have a written plan.

Thursday, December 6, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 248)

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, December 5, 2018

CVS Health launches "New" Guaranteed Net Cost Pricing Model

Source:  Pharmacy Benefits Management Institute 
Under the new model, CVS Health will return 100% of drug rebates to employer-sponsored groups and at some point in the future government health programs. The good news is this moves the entire industry one step closer to radical transparency. The bad news is CVS Health admits it hoodwinked all those clients it sold pass-through arrangements. Those so-called pass-through agreements were nothing more than fee-for-service [opaque] pricing models disguised as pass-through contracts.

It's safe to assume Caremark's (CVS Health's PBM) gross margins will grow next year or worst case remains flat. Shareholders wouldn't have it any other way. So it begs the question, "how?" Here are a few ideas:

Tuesday, December 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.

Monday, December 3, 2018

Union takes to task pharmaceutical manufacturer on a $6,000,000 per year specialty drug

Click to read the entire letter to POTUS
On Monday, November 26, 2018, the Trump administration proposed a set of strategies to lower pharmaceutical costs in Medicare Part D. As set out in the proposed rule, the plan has three major new provisions:

1) Providing Part D plans with more flexibility to manage protected classes

2) Updating existing e-prescribing systems to make patients’ costs visible when a prescription is ordered

3) Requiring pharmacy price concessions for drugs at the point of sale

On the heels of this proposal, I want to share with you a letter written by Boilermakers National Health & Welfare Fund (BNF) to POTUS which clearly illustrates why the proposed changes are necessary. I am posting the letter in its entirety with permission from BNF's COO, Lori Jasperson.

In short, BNF has one family on Strensiq, a new specialty drug manufactured by Alexion Pharmaceuticals, with a projected price tag of $6,000,000.00 per year! Rather than take that price lying down, BNF decided to get the CEO of Alexion on the phone.

In my hood, we have a euphemism for this sort of action "pressure bursts pipes" no pun intended Lori. Read the letter and the result of those phone conversations by clicking here.

Thursday, November 29, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 247)

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, November 28, 2018

4 Key Factors Employers Must Consider When Evaluating Specialty Pharmacy Performance

A PBMs performance should be measured by the sum of its parts, not the whole. Employers should work with PBMs to understand how its preferred specialty pharmacy compares with industry benchmarks, and determine where the incumbent is exceeding or falling short of those benchmarks.

Source: BCBS Prescription Drug Costs Trend Update Report

Employers must consider the following four key factors in their evaluation of specialty pharmacies:

1. Specialty drug spending at the patient, drug and therapeutic category levels. In this case, employers should compare the rebates passed through by non-fiduciary PBMs and those from fiduciary-model PBMs.

2. Clinical outcomes and the value realized from the specialty drug spend.

3. Savings from unnecessary or avoided hospital, clinic, and emergency room visits.

4. Patient and provider satisfaction.

Ensuring only high-performing specialty pharmacies in PBM pharmacy networks benefits both employers and patients, as a result of improved patient adherence and the elimination of wasteful Rx spending.

Monday, November 26, 2018

State Settles $500k Dispute with a Big Three Pharmacy Benefits Manager

Click to Learn How
The Attorney General’s Office and the Vermont Department of Human Resources have settled a dispute with the State’s pharmacy benefits manager for $503,500. The State’s pharmacy benefits manager, Express Scripts, oversees management of prescription benefits for the State’s employees and retirees.

Tyrone's Commentary:

I want more than anyone that PBMs deliver radical transparency to their clients. I don't, however, believe organizations should be able to clawback overpayments from non-fiduciary PBMs for a bad deal it willingly signed. So, it makes me wonder why did Express Scripts settle when for decades it has thumbed its nose at complaints about overpayments? Winning radical transparency from non-fiduciary PBMs boils down to two things; knowledge and grit. Occasionally, the threat of a lawsuit or moving business to a competitor doesn't hurt.

The State will receive the settlement amount in increased guaranteed prescription rebates payable in 2019 for prescriptions purchased in 2018. The settlement resolves a dispute about charges paid by the State several years ago under a now-expired contract.

[Read More]

Wednesday, November 21, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 246)

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, November 19, 2018

Express Scripts announces "new" formulary that favors lower-cost generics

...I was under the impression PBMs already favored lower-cost generics?
Express Scripts announced last week a new "formulary," or list of covered drugs, that will favor lower-cost generic versions of the drugs rather than expensive, branded versions. Now its clients, including both health insurers and employer plans, can choose between lists that include drugs with a high list price -- and high rebate to PBMs like Express Scripts -- or the new list with lower-price drugs but with little or no rebate.

Tyrone's Commentary:

TransparentRx has favored lower-cost generics over higher cost brand drugs, regardless of rebates, for almost a decade! In fact, we've shunned potential business from employers who viewed rebates as "free" money and wanted to steer our formulary toward that end. It will be interesting to see if the conflicts of interests and misaligned incentives, some brokers and consultants benefit from, begin to dissipate in favor of putting the needs of members and employers first. It's time we start measuring value across all stakeholders with radically transparent data and conversations. 

Under the current model, drug manufacturers set a list price for their medications and negotiate a rebate off that price with PBMs in exchange for having their medicines placed on a list of covered and preferred medicines. Experts say it’s not always clear who gets the rebate, but part of it goes to employers or insurance companies while PBMs also keep a percentage. This model leads to higher costs for patients as drugmakers increase list prices to offset the cost of rebates.

[Read More]

Thursday, November 15, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 245)

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, November 14, 2018

Achievement is Significant But Comes with a Huge Price Tag: New Regulation Requires Regulatory Oversight of Pharmacy Benefit Managers (“PBMs”)

Click to Enlarge
This achievement is bittersweet so allow me to provide the back story. Approximately four years ago, we applied to the Nevada Division of Insurance, our home state, to become a continuing education service provider.

A primary benefit of being certified in our home state is reciprocity. This means approval by our home state would be recognized by every other state in the country without having to go through the full application process within those states. Reciprocity reduces cost and significantly reduces the administrative burden. We assumed getting approved as a CE (continuing education) provider in the same state for which we are domiciled was a no-brainer until it wasn't!

Because the state of Nevada didn't regulate PBMs, TransparentRx's initial application to become a CE provider was not approved. Those of you familiar with these sorts of applications know that you can't just try once and give up. You must push through and sometimes that requires educating or partnering with the entity who has the final say so.

Thursday, November 8, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 244)

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, November 7, 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.

Tuesday, November 6, 2018

Unless Your Company Has Money to Burn Don't Ignore These 7 PBM Contract Pitfalls

One of the first questions I often get during a new consulting assignment centers around cost data. More specifically, analyzing the cost of one proposal against that of another PBM vendor. When this happens I know there could be some trouble ahead for our partnership.

Where costs are concerned, I'm most concerned with whether or not rebates, discount rates and dispensing fees are competitive. It takes all of 30 minutes to compare these data points among 5 to 7 competing PBM vendors. Once I know pricing is competitive my attention turns to the contract.

You see PBMs don't set prices they negotiate for better pricing which is different than setting prices. All bets are off if the PBM repackages directly via a mail-order pharmacy or indirectly through say a national chain of retail pharmacies. More about this later.

During Bill Clinton's 1992 successful presidential campaign, James Carville coined the phrase "It's the economy, stupid!" For our purposes and stealing a page from James Carville, "It's the contract, stupid!" All kidding aside, the contract will determine what you ultimately pay so in a sense words matter more than numbers.

Here are seven PBM contract pitfalls you should not ignore.

1. Begin procurement at least six months before the renewal date to put your company in the best position to drive a hard bargain. The first day of procurement starts when you've sent the RFI notification letter not when you're just talking about renewal. Don't wait too long before you begin procurement. Incumbent PBMs and other stakeholders love it when the process is rushed. The reasons should be obvious.

Thursday, November 1, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 243)

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, October 30, 2018

Most employers (60%) aren't tracking wasteful healthcare spending

Related image
Breakdown of the sources of health care wasteful pending
Most employers are not collecting or analyzing data to track unnecessary healthcare spending, even though they see waste as a problem, according to the survey from National Alliance of Healthcare Purchaser Coalitions.

Healthcare is estimated to waste more than $750 billion annually, and respondents said they view this is a problem. More than half of them  (57 percent) said they believe up to 25 percent of treatments employees and dependents receive are unnecessary.

The survey involved 126 U.S. employers in several industries, including manufacturing, education, financial services and healthcare. For the purposes of the survey, waste was defined as "procedures and treatments that are overused, have limited effectiveness, and/or are repetitive to tests and procedures that have already been conducted."

Four findings:

1. A majority of survey respondents (59%) don’t collect and analyze data in order to track waste. 

2. One-third of employers in the survery (34%) farm out that task to at least one vendor (such as a pharmacy benefits manager, a health plan, or a consultant). 

3. Only 7% of those surveyed said their organization tracks waste internally.

4. Respondents cited medical imaging, specialty drugs, prescription medications and  clinical tests as the largest contributors to waste.

Tyrone's Commentary:

A critical component to eliminating wasteful Rx spending is a leadership-instilled culture of learning. A learning employer is stewarded by leadership committed to a culture of teamwork, collaboration and adaptability in support of continuous learning as a core aim

In a learning culture the employer takes ownership and doesn't kick the can down the road. Complex PBM operations and processes are constantly refined through ongoing team training and skill building, systems analysis and information development, and creation of the feedback loops for continuous learning and system improvement. 

Friday, October 26, 2018

PepsiCo and ExxonMobil Team Up with Express Scripts to Create Pharmacy Benefit Design for Radical Transparency and Greater Performance Accountability

Hidden cash flows to non-fiduciary PBMs make up for artificially low administrative fees
It seems the NDPC has fixed this problem have you?

The National Drug Purchasing Coalition (NDPC), an employer-led coalition, is announcing the Total Performance Management solution for its members: a transformative new way for employers to provide pharmacy benefits that guarantees pricing transparency, alignment on outcomes, and accountability for performance.

Express Scripts worked closely with the NDPC to develop the innovative solution. NDPC member companies include PepsiCo, Inc.; ExxonMobil; Chevron Corporation; Sodexo; Yum! Brands, Inc.; Solvay USA Inc., and others.

The Total Performance Management offering is a novel pharmacy benefit model providing employers with more transparency to the true costs of prescription medications, alignment with Express Scripts on clinical, service, and financial performance goals for the plan, and accountability from Express Scripts for delivering on those goals.

The new model has two areas of focus:
  • Pay-for-performance for clinical and administrative plan management that improves patient and plan outcomes. Pay-for-performance means Express Scripts will take on more risk from clients, and be rewarded only when it delivers on agreed-to commitments.
  • Clients pay what Express Scripts pays for prescription drugs plus administrative fees ensuring clients have the transparency they want. By adding clarity to costs, our clients will have a more direct line of sight to the true cost of drugs net of all manufacturer discounts, rebates and incentives.
Tyrone's Commentary:

It's about time! However, the model isn't new so don't be fooled by the marketing spin. Nonetheless, it is the right thing to do and for that I must applaud both NDPC and Express Scripts. NDPC should be credited for demanding radical transparency and Express Scripts for delivering on plan sponsor requirements for more transparency. Three things the coalition must execute on now that radical transparency is seemingly in their grasp:
  1. Continuously monitor PBM performance which goes far beyond standard or ad hoc reports.
  2. Not allow Express Scripts to clawback lost revenues by overcharging for standard or ancillary services.
  3. Prevent Express Scripts from shifting costs to the medical pharmacy spend. I don't know if Express Scripts makes this deal if not for the merger with Cigna.

Thursday, October 25, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 242)

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, October 23, 2018

UnitedHealth has bought another billion-dollar pharmacy business

UnitedHealth Group Inc.’s Optum business has disclosed it bought Avella Specialty Pharmacy, a previously unannounced deal that closed in the third quarter. The Minnetonka-based health care giant revealed the acquisition in an earnings announcement Tuesday.

Phoenix-based Avella distributes specialty drugs, which typically are high-cost and treat complex conditions. UnitedHealth didn’t disclose terms of the deal, which will bring Avella under the umbrella of the United's OptumRx pharmacy-benefits unit.

Source: Statista

The deal was OptumRx’s second acquisition in recent months. It also bought Renton, Wash.-based Genoa Healthcare, which operates pharmacies inside mental-health centers and provides telepsychiatry services.

Avella generated about $1.4 billion in revenue from prescription drugs last year, up 6 percent from a year earlier, according to Drug Channels Institute research. It had roughly 700 employees as of 2016, according to the Phoenix Business Journal.

[Read More]

Thursday, October 18, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 241)

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, October 15, 2018

Another big PBM has confirmed it's primary objective isn't to contain prescription drug costs

It is no secret that non-fiduciary pharmacy benefit managers will generally rely on the demands of clients, both current and prospective, for the level of transparency and disclosure it will provide. Express Scripts confirmed as much in the 60 minutes episode The Problem with Prescription Drug Prices by stating and I quote, "it is not contractually obligated to contain costs." If you haven't watched the 60 minutes episode you can read the transcript here.

Now CVS Health has admitted as much as well. In its Q2 2018 earnings call CVS Health writes, "We underwrite contracts to overall level of profitability and many levers available to pull, depending upon the preferences of the client." In layman's terms here is what that means...

CVS HEALTH WILL GENERATE AS MUCH REVENUE AS POSSIBLE AND HOW MUCH WE ARE ABLE TO GENERATE WILL DEPEND LARGELY ON HOW SOPHISTICATED OR UNSOPHISTICATED OUR CLIENTS MIGHT BE.

Non-fiduciary PBMs are couting on two things from self-insured employers:

Thursday, October 11, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 240)

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.

Thursday, October 4, 2018

Reference Pricing: "Gross" Invoice Cost for Popular Generic and Brand Prescription Drugs (Volume 239)

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, October 3, 2018

A Tough Negotiator Proves Employers Can Bargain Down Health Care Prices

Radical transparency in pharmacy benefits management
starts with training and education. Click here to begin yours.
Marilyn Bartlett took a deep breath, drew herself up to her full 5 feet and a smidge, and told the assembled handful of Montana officials that she had a radical strategy to bail out the state's foundering benefit plan for its 30,000 employees and their families.

The officials were listening. Their health plan was going broke, with losses that could top $50 million in just a few years. It needed a savior, but none of the applicants to be its new administrator had wowed them.

Now here was a self-described pushy 64-year-old grandmother interviewing for the job. Bartlett came with some unique qualifications. She'd just spent 13 years on the insurance industry side, first as a controller for a Blue Cross Blue Shield plan, then as the chief financial officer for a company that administered benefits. She was a potent combination of irreverent and nerdy, a certified public accountant whose Smart car's license plate reads "DR CR," the Latin abbreviations for "debit" and "credit."

Tyrone's Takeaways:

1)  Self-funded employers don't know what they don't know thus put too much trust in those who purport to have "the" solution but are really most interested in padding their own pockets.

2)  If you're a plan sponsor, get someone on your side who puts you first contractually not just lip service. This person must also have P&L responsibility experience from the other side (i.e. health plan, PBM or drugmaker) or at the very least trained by someone who has the requisite qualifications.

3)  Don't settle for anything less than radical transparency, Marilyn didn't.

4)  The more sophisticated you are as a purchaser the less you pay without cutting benefits to employees or raising their cost share. 

5) A co-op or coalition aren't always the better deal. They often leverage the purchasing power of members for their own financial advantage.

6) I would like to buy Marilyn Bartlett a beer. Marilyn if you're reading this call a brotha!

Health plans contract with separate companies, middlemen entities known as pharmacy benefit managers, to get members their medication. And everyone assured Bartlett the state's pharmacy benefits deal was "state of the art." But just like with Cigna, she insisted on examining it herself.

That wasn't easy because the pharmacy benefits were run through a cooperative arrangement with other health plans, including those of universities, school trusts and counties. The state plan anchored the co-op, and the other partners were happy with the arrangement.

Bartlett knew that pharmacy benefit managers are notorious for including deals that boost their profits at the expense of employers. One of the common tricks is called the "spread." A pharmacy benefit manager, for example, will tell an employer it cost $100 to fill a prescription that actually cost $60, allowing the pharmacy benefit manager to pocket the extra $40. The fine print in the contracts often allows it.

The spread is widespread. A recent report by the Ohio state auditor noted that the spread on generic drugs had cost that state's Medicaid plan $208 million in a single year — 31 percent of what it spent.

Sure enough, when she got the contract, Bartlett found that the state plan had fallen victim to the spread.

[Read More]

Tuesday, October 2, 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.