One of the most powerful middleman industries in the global economy is emerging from more than a half-decade of difficult transition. Drug distributors purchase drugs, often entire lines of drugs, from manufacturers. They warehouse and sell them to retail chains and mail-order, online and specialty pharmacies, as well as to physician offices and clinics. Three companies dominate this key piece of the pharmaceutical supply chain. The largest, San Francisco-based McKesson (MCK ), reported almost $138 billion in fiscal 2014 revenue. The companies earn slim margins from their massive revenue, however. And those thin profits have come under harsh pressure in recent years due to shifting trends in health care. AmerisourceBergen (ABC), McKesson and Cardinal Health (CAH ) have been able to withstand this squeeze largely because they've combined their purchasing power with major pharmacy chains Walgreen Boots Alliance (WBA ), Rite-Aid (RAD ) and CVS Health (CVS). Source:  www.fda.gov The three dominant drug distributors control more than 85% of the market. Their stocks have trended higher the past five years, with AmerisourceBergen up 29%, McKesson up 27% and Cardinal Health ahead 20% the past 12 months. Challenges And Benefits The drug wholesaler-drugstore partnerships unite the two middlemen in the pharmaceutical supply chain. Their common bond is in wanting to defend the spread between the wholesale price the manufacturer charges and the retail price that the insurer lets pharmacies bill patients. That spread can be paper-thin for branded drugs, and often substantially wider for generics. The catalyst for the distributor/pharmacy chain deals: "The payers in the U.S. have been looking at every single option to lower prices," said Vishnu Lekraj, health care service analyst at Morningstar. This price pressure, applied by the pharmacy benefit manager side, leverages the PBMs' market power to control prices on behalf of insurers, Lekraj said. The AmerisourceBergen-Walgreen, Cardinal Health-CVS and McKesson-Rite Aid ventures have each elevated their generics purchasing to $10 billion to $12 billion a year, estimates FBR Capital Markets data. By joining together, drug wholesalers and drugstores can better withstand the profit squeeze and pass most of the pricing pressure onto generic drug manufacturers, Lekraj says. That advantage until recently has remained largely theoretical, although the partnerships have begun to bear fruit. Rite-Aid's latest quarterly results demonstrate the value provided by its deal struck last February to have McKesson purchase its generic drugs and deliver them directly to stores, notes Fein. The pharmacy chain's total inventories were $255 million below year-ago levels in the third quarter, a boon to working capital and profit margins. "If Rite Aid keeps posting such positive results, expect other large pharmacy buyers to give in ... and begin sourcing generics through the large wholesalers," he wrote on his Drug Channels blog. One wrinkle to McKesson's partnership with Rite Aid: the distributor's plans to use its own NorthStar generic manufacturing arm for some generic production, providing more pressure on generic-drug makers to make concessions on price. McKesson suppliesWal-Mart (WMT) with branded drugs, but the retailing giant currently buys its own…

Why is this document important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to healthcare reform.  The costs shared below are what our pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to "reference pricing." Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders.  Note: This document is updated weekly to reflect changing prices and new products. Did you know that pharmacies (and PBMs) often negotiate discounts on prescription drugs which aren't reflected in AWP, WAC or MAC prices? The only way to be sure you're receiving these discounts is to gain access to invoices. How to Determine if Your Company [or Client] is Overpaying Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month. Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list. Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement.  It's impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions. Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our pharmacy cost then determine if a problem exists. When there is a 5% or more price differential (paid versus actual cost) we consider this a problem.   Multiple price differential discoveries means that your organization or client is likely overpaying. REPEAT these steps once per month.   -- Tip --   Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine if better pricing is available in the marketplace compared to what the client is currently receiving.  When better pricing is discovered the contract language should stipulate the client be indemnified. Do not allow the PBM to limit the market check language to a similar size client, benefit design and/or drug utilization.  In this case, the market check language is effectually meaningless. Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]

My 12-year-old daughter suffers from asthma, so when she left her inhaler at home during a family trip to Nebraska this fall, we had to replace it. I ordered a new inhaler at the local pharmacy and was shocked when the pharmacist told me it would cost $60. The charge was manageable, but the experience opened my eyes to the dangers of monopolies in the pharmaceutical industry. When the pharmacy told me how much the name-brand version of my daughter's albuterol inhaler would cost, I inquired about the generic. I used to work in a traditional retail pharmacy, and remembered being able to obtain the generic version for about $2. The manager informed me that there was no longer a generic albuterol inhaler available. A few years ago, pharmaceutical companies successfully lobbied the Food and Drug Administration ( to ban traditional inhalers over fears that the chlorofluorocarbon (CFC) used as a propellant was harmful to the ozone layer. The patents on those traditional inhalers had expired, so generic versions were readily available. The ban enabled drug makers to use new propellants, which could justify a new patent for the same drug. As a result, the price went from a few dollars per prescription to $60. Source:  www.uspharmacist.com A new report in the New England Journal of Medicine highlights how big the problem of high-cost generic drugs is getting. Generic drugs to treat everything from intestinal parasites to high blood pressure to depression have increased 570 percent, 2,800 percent and 5,200 percent, respectively — sometimes in as little as one year. In 2012, the McKesson Corporation paid out $151 million to 29 states over allegations that the company artificially raised Medicaid drug prices. McKesson is the country's largest drug wholesaler, and it was alleged that they artificially drove up prices on 1,400 drugs from 2001 to 2009. Going forward, it looks as if things will only get worse. Bryan Birch, the chief executive of Truveris, which analyzes prescription drug prices, recently spoke to Medscape Medical News about the "unprecedented levels of generic price increases" over the last two years. "The folks who benefit from it are the manufacturers of generic drugs, the wholesalers in the United States, and the...pharmacy benefits managers," Birch said, adding that the costs are eventually passed on to consumers. When there is a legitimate shortage of generic drugs, the FDA can usually work to expedite companies' ability to produce the drug, or even deal with overseas manufacturers to import more of the drug. Compounding, when a pharmacist creates a customized medication on a case-by-case basis, is another alternative for patients who need drugs that are hard to find commercially. But the FDA cannot do the same with a single manufacturer of a drug, according to the NEJM report. "U.S. antitrust laws protect consumers only from anticompetitive strategies such as price fixing among competitors," the report notes. "Manufacturers of generic drugs that legally obtain a market monopoly are free to unilaterally raise the prices of their products." I'm…

Why is this document important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to healthcare reform.  The costs shared below are what our pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to "reference pricing." Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders.  Note: This document is updated weekly to reflect changing prices and new products. Did you know that pharmacies (and PBMs) often negotiate discounts on prescription drugs which aren't reflected in AWP, WAC or MAC prices? The only way to be sure you're receiving these discounts is to gain access to invoices. How to Determine if Your Company [or Client] is Overpaying Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month. Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list. Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement.  It's impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions. Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our pharmacy cost then determine if a problem exists. When there is a 5% or more price differential (paid versus actual cost) we consider this a problem. Multiple price differential discoveries means that your organization or client is likely overpaying. REPEAT these steps once per month. -- Tip -- Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine if better pricing is available in the marketplace compared to what the client is currently receiving.  When better pricing is discovered the contract language should stipulate the client be indemnified. Do not allow the PBM to limit the market check language to a similar size client, benefit design and/or drug utilization.  In this case, the market check language is effectually meaningless. Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]

Click image to enlarge The impact of specialty drugs continues to increase in both drug utilization and spend. In 2012, specialty drug spend accounted for approximately $87 billion, or about 3.1% of national health spend in the United States. In 2020, the forecasted specialty drug spend is expected to be $400 billion, or about 9.1% of national health spend. In addition, within 4 years, analysts predict that 7 of the top 10 drugs in terms of sales will be specialty products.1 Given this expected growth, the specialty drug pipeline will be of particular interest to patients, prescribers, payers, and pharmacies. New specialty drug approvals As of December 3, 2014, FDA had approved 39 new molecular entities and new therapeutic biologics this year. While there is no universal definition of a specialty drug, approximately 19 of this year’s approvals fit commonly used definitions of specialty products (Table 1).6,7 Of these 19, oncology and rare diseases represented the majority of approvals, a trend that is expected to continue through 2015.2 In The Pipeline
 Oncology Looking ahead to the remainder of 2014 and 2015, the pipeline is again forecasted to have the highest number of approvals in oncology, with approximately one dozen expected approvals for a variety of cancers (Table 2).3 Programmed cell death–1 (PD-1) drugs stand out as an especially promising class of therapy. Pembrolizumab (Keytruda—Merck) was the first of this class to earn FDA approval for the treatment of unresectable or metastatic melanoma. Pembrolizumab, along with fellow experimental PD-1 drug nivolumab (Opdivo—Bristol-Myers Squibb), have earned breakthrough designations from FDA and are likely to see success expanding into other indications. Trials are currently under way with PD-1 agents for a number of cancers, including lung, liver, brain, and solid tumors. Other pipeline drugs are in late stages of development for the treatment of breast, melanoma, non–small cell lung, ovarian, and pancreatic cancers, as well as hematologic malignancies such as leukemia and multiple myeloma. Click image to enlarge Hepatitis C Hepatitis C (HCV) continues to have one of the most intriguing pipelines of any disease state. Within the last year, the approvals of sofosbuvir (Sovaldi—Gilead) and simeprevir (Olysio—Janssen) as individual agents have led to major changes in the treatment of HCV. Gilead’s Harvoni, the combination of sofosbuvir and ledipasvir, was approved in October 2014. In addition, sofosbuvir and simeprevir used together was approved in November 2014. Both of these combination therapies show high sustained viral response rates and are interferon-free, oral regimens. Competition should come from the AbbVie “3D” HCV combination therapy composed of ombitasvir, paritaprevir, and ritonavir (Viekirax) used in combination with dasabuvir (Exviera). An FDA decision for this combination is expected by December 22, 2014. In addition, Merck’s HCV combination of MK-5172 and MK-8742 is also showing good effectiveness in clinical trials. Tough competition from fast-paced innovation in the HCV market has taken a toll on other pipeline agents. Faldaprevir, a late-stage drug from Boehringer Ingelheim, was abandoned. Bristol-Myers Squibb’s daclatasvir and asunaprevir, taken together as a two-drug combination therapy, was…

Why is this document important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to healthcare reform.  The costs shared below are what our pharmacy actually pays; not AWP, MAC or WAC. The bottom line; payers must have access to "reference pricing." Apply this knowledge to hold PBMs accountable and lower plan expenditures for stakeholders.  Note: This document is updated weekly to reflect changing prices and new products. Did you know that pharmacies (and PBMs) often negotiate discounts on prescription drugs which aren't reflected in AWP, WAC or MAC prices? The only way to be sure you're receiving these discounts is to gain access to invoices. How to Determine if Your Company [or Client] is Overpaying Step #1:  Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month. Step #2:  In addition, request an electronic copy of all your prescription transactions (claims) for the billing cycle which coincides with the date of your price list. Step #3:  Compare approximately 10 to 20 prescription claims against the price list to confirm contract agreement.  It's impractical to verify all claims, but 10 is a sample size large enough to extract some good assumptions. Step #4:  Now take it one step further. Check what your organization has paid, for prescription drugs, against our pharmacy cost then determine if a problem exists. When there is a 5% or more price differential (paid versus actual cost) we consider this a problem.   Multiple price differential discoveries means that your organization or client is likely overpaying. REPEAT these steps once per month.   -- Tip --   Always include a semi-annual market check in your PBM contract language. Market checks provide each payer the ability, during the contract, to determine if better pricing is available in the marketplace compared to what the client is currently receiving.  When better pricing is discovered the contract language should stipulate the client be indemnified. Do not allow the PBM to limit the market check language to a similar size client, benefit design and/or drug utilization.  In this case, the market check language is effectually meaningless. Click here to register: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels." [Free Webinar]

Many times clients go through great effort putting together an RFP for PBMs to answer in great detail questions about pricing, service level, and others.  Herein lies the problem; little of this pricing information gets put into the contract.  Those 25 pages or more of useless information could've been put to better use by reducing your carbon footprint. If a PBM expects to gain your trust and manage your pharmacy benefit, it is only reasonable they sign a fiduciary contract which reflects their claims to transparency. If the PBM agrees to your terms, it only follows that your plan goals are memorialized in a rock solid contract. RFPs do not bind a PBM to their guarantees, fiduciary contracts do. You must eliminate the RFP process and instead draft an airtight fiduciary contract and put it out for bid. A contract is not a legal agreement until it is signed by all parties involved.  Consider this; Many times financial guarantees are not guarantees unless the client has spelled them out in a fiduciary contract.  All rebates may not be paid unless a fiduciary contract is signed. Full audit provisions generally will not be honored unless you have a signed fiduciary contract and a RFP is not a contract.  However, a signed agreement in a well drafted contract that honors the best that a PBM can offer through the RFP process is worth celebrating with concrete savings. The best type of contract, without question, is a fiduciary contract. Fiduciary contracts provide the highest level of care and deliver perpetual cost reductions to plan sponsors. That being said, why would you settle for anything less? Click here to register for: "How To Slash the Cost of Your PBM Service, up to 50%, Without Changing Providers or Employee Benefit Levels."

As the year winds down, many employers are reviewing 2014 expenses to help plan spending for the new year. One of the main expenses for many organizations is the cost of employees’ health care. These costs seem to go up every year, but why? According to America’s Health Insurance Plans, a national trade association, health care spending nationwide rose at its fastest pace in 10 years in the fourth quarter of 2013. The main reasons are the rising costs of medical services such as hospital care, costly new drugs and medical technologies, and the impact of hospitals and physician offices consolidating, leaving less competition. One of these reasons may surprise employers — the availability of new and costly prescription drugs, also known as specialty drugs. Specialty drugs are used to treat complex conditions such as cancer, cystic fibrosis, hemophilia, multiple sclerosis or psoriasis. You may have seen advertisements or news reports about the drugs Humira for treating inflammatory conditions such as rheumatoid arthritis or Crohn’s disease, and Harvoni for treating hepatitis C. Specialty drugs are usually injected or infused, but also may be taken orally. And many of these drugs show great results in treating complex, chronic conditions and allowing patients to live fuller, longer lives. Specialty drugs are used to treat serious conditions and can be complex to manufacture, the cost can be significant. The 2014 EMD Serono Specialty Digest reports that 3.6 percent of patients who use specialty drugs account for 25 percent of health care costs. Data from Express Scripts, a national pharmacy benefits manager, shows the average cost of filling a specialty drug prescription for one month is $1,800 compared to $54 for other prescription drugs. CVS Caremark also projects that the costs of the entire specialty drug market will reach $402 billion by 2020. Thanks to advanced research, more than 900 specialty drugs are in various stages of development. Knowing that an employee who has a complex medical condition such as cancer now has access to new and better treatments is certainly good news. But employers must understand that when health care costs increase for employees, so do health insurance premiums. The National Institute of Health Care Management Foundation attributes 97 percent of the rise in premium spending between 2006 and 2010 to increased spending by insurers to cover the actual health care costs of members. We encourage employers to be aware of the drivers of health care costs and health insurance premiums and to work with their insurer to help manage those costs. [Publisher Comment:  work with your insurer to better manage rising prescription drug costs, but utilize the services of a PBM expert, internal or external, to hold the insurer/TPA accountable.  Insurers will surely take advantage of gaps in your knowledge in order to maintain their profit.] For example, many health insurers implement utilization management procedures to help ensure that members receive coverage for the right medications to treat the right conditions. Many insurers work with employers to offer workers access to lower…

Source: Pembroke Consulting For decades, generic prescription drugs have been considered the bargains of the pharmaceutical world. An industry group says Americans have saved more than $1.5 trillion in the past 10 years on brand name drugs, thanks to generics. But in recent months, prices on some of the most popular drugs have soared, and experts are trying to figure out why. Buying generic prescription drugs feels like trading on the stock market for Cory Minnick. "Just seems to snowball every month, it gets worse and worse. You see stuff you used to buy for pennies for a hundred, and now you're paying $70 to $80 just to get it in," he says. Minnick, pharmacy manager at Royer’s on Sharp Avenue in Ephrata, Lancaster County, says he’s constantly checking with his three wholesalers to see what it’s going to cost to get a drug in the hands of a customer. The popular antibiotic doxycycline is used to treat common problems like urinary tract infections and pneumonia.  It cost a mere $20 for a 500 pill supply in October 2013. Yet this past April, its price had hit more than $1,800. Don’t do the math on the percentage increase, it could get ugly. By the way, doxycycline has been on the market for 40 plus years, and the formula hasn’t changed. So what’s going on here? Drugs have "life cycles" "These recent drug shortage and price hikes illustrate a third stage of the life cycle of a drug that we haven't really paid much attention to yet," says Jeremy Greene, a Johns Hopkins professor and author of Generics: the Unbranding of Modern Medicine. "What happens when a drug is no longer particularly attractive to generic manufacturers? Or when the interests of the generic marketplace continue to go towards the second pipeline, the pipeline of drugs that are going off patent now and the drugs that have been off for patents for a while are no longer particularly attractive and get neglected," he says. Greene says drugs used to have two cycles – the brand name stage, where the patent protects the work done by companies like Pfizer, and helps them recoup their investment in research. But then the patent expires, and all manufacturers have a shot to make and sell the drug, ideally, at a much lower cost. That what Ralph Neas, President of the Generic Pharmaceutical Association is focusing on. "It may go up 50% or a 100%, whatever it might but you’re still in the pennies and sometimes you get up to a couple dollars. A very few number are more than that," says Neas. Here’s what we know: In 2010, the average cost of one of the 50 most prescribed generics was $13. In 2013, it hit $62. That data comes from Catamaran, which manages pharmacy benefits for 32 million people. Why are prices rising? A lot of theories are floating around, but the most prominent ones deal with raw material shortages and less competition.  To continue reading…

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