Author: Tyrone Squires, MBA, CPBS

This author has written 1273 articles

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.

The Insurance Industry is Picking a Fight with Pharmaceutical Companies Over the Rising Cost of Specialty Drugs

The insurance industry is picking a fight with pharmaceutical companies over the rising cost of specialty drugs.
Insurers say the high prices are raising healthcare costs for insurance companies and everyone else, threatening the sustainability of the U.S. healthcare system.

Drug makers say the high prices are necessary to recoup research and development costs. They also say insurers should cover more of the cost of pharmaceuticals.

The fight has been waged as a full-fledged feud in Washington between America’s Health Insurance Plans (AHIP), the lobbying group for insurers; and the Pharmaceutical Researchers and Manufacturers of America (PhRMA).
In the last week, AHIP CEO Karen Ignagni has launched a full-on public relations assault against drugmakers, who AHIP says threaten to threaten to bankrupt families and bust government healthcare budgets.
“Is this ‘whatever you can get away with’ pricing here?” Ignagni asked during a healthcare conference hosted by the New York Time on Thursday. “Is that the right thing for the future?”
Ignani questions whether U.S. consumers are subsidizing lower drug prices in other countries. And during another recent healthcare conference hosted by The Atlantic, Ignagni warned if stakeholders do not fix the rising cost of drugs, the government may end up legislating drug costs.
The catalyst for this fight is Gilead’s $1,000-per-pill Sovaldi, which is used to treat Hepatitis C. A patient required to take one pill a day for 24 weeks would have to pay $168,000.
AHIP has lambasted the drug’s cost. And while Gilead is not a member of PhRMA, the lobby group has come to its defense.
“It is penny wise and pound foolish to focus solely on the price of a new medicine while completely ignoring the value it provides to patients and the health care system broadly,” said John Castellani, PhRMA CEO.
“Curing Hepatitis C not only dramatically improves patients’ lives, but has the potential to save the U.S. health care system as much as $9 billion per year by preventing expensive hospitalizations and avoiding thousands of liver transplants that routinely cost over $500,000 each.”

Read more: http://thehill.com/policy/healthcare/207803-rising-drug-prices-trigger-civil-war-between-healthcare-lobbies#ixzz33U8PDHew

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.

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.

Plan Sponsors’ Satisfaction With PBMs Remains Relatively Unchanged

The Pharmacy Benefit Management Institute (PBMI) released its 2014 PBM Customer Satisfaction Report based on its annual survey of drug benefit plan sponsors. The report shows a mean overall satisfaction score of 7.5 on a 10-point scale, a result that has remained relatively unchanged for the past five years. The 2014 survey was completed by 394 U.S. plan sponsors representing more than 64.7 million enrollees. 
 
PBMs are rated not only on their overall performance, but also on specific functions and services, including those related to specialty (“biotech”) drugs. The survey is regularly updated to reflect market trends. This year’s survey included two new service dimension ratings: commitment to good customer service and meeting financial guarantees. 
 
The following highlights key findings from the report:
  • Comparing plan sponsor types (health plans, employers, and unions), little variation is found in overall satisfaction or satisfaction with specific service dimensions, PBM functions, or non-core services.
  • The percentage of respondents indicating that their financial relationship with their PBM is completely transparent grew significantly this year, up to 44% versus 35% in 2013.

Read more: http://www.digitaljournal.com/pr/1848618#ixzz31bU0BKR7

 

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.

IMS Report: Specialty Medications Drive Prescription Drug Spending Increase

Spending on specialty medications continues to grow, and the gap between the cost of treating medical conditions with generic drugs and the cost of treating more serious illnesses with specialty drugs continues to widen, according to a report released on April 15, 2014, by the IMS Institute for Healthcare Informatics. The report finds that total spending on prescription medications rose by 3.2% to $329.2 billion in 2013.

The increase was attributed to a variety of factors, including higher costs for new specialty drugs, as use of health care services by consumers went up for the first time in 3 years. “Following several years of decline, 2013 was striking for the increased use by patients of all parts of the U.S. health care system—even in advance of full implementation of the Affordable Care Act,” said Murray Aitken, executive director of the IMS Institute for Healthcare Informatics, in a press release.

“Growth in medicine spending remains at historically low levels despite a significant uptick last year, and continues to contribute to the bending of the health care cost curve.” Patients with rare or serious conditions were found to bear a much larger burden from out-of-pocket costs than did patients who do not need specialty drugs.

The report states that 30% of consumer drug spending last year came from just 2.3% of prescriptions, which had co-pays of more than $70 and which were frequently specialty medications. (Consumers paid an average of $145 in out-of-pocket expenses for these medications.)

See more at: http://www.specialtypharmacytimes.com/news/IMS-Report-Specialty-Medications-Drive-Prescription-Drug-Spending-Increase#sthash.jR6uXBGG.dpuf

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.

Early Pharmacy Claims Data from Exchange Enrollees Indicate High Usage

When setting rates for qualified health plans sold through public exchanges a year ago, actuaries anticipated that people who purchased coverage through an exchange would be older and less healthy than the commercially insured population. They also assumed there would be pent-up demand for pharmaceuticals and care. 

Now that exchanges are up and running, preliminary drug claims data is showing such a trend. The April 17 issue of Atlantic Information Services, Inc.’s Inside Health Insurance Exchanges (HEX) walks readers through data from two pharmacy benefit managers (PBMs) and what it means for insurers.

During the first two months of 2014, exchange enrollees were more likely to use costly specialty drugs when compared to those with coverage outside of the exchanges, according to preliminary claims data released April 9 by Express Scripts. 

According to the early data, six of the 10 costliest medications used by exchange enrollees were specialty drugs versus four of the top 10 used by commercial health plan enrollees. Of total prescriptions filled for exchange plans, 1.1% was for specialty drugs, compared with 0.75% in commercial plans — a near-50% difference.

Read more: http://www.digitaljournal.com/pr/1867253#ixzz2zipbRF40