That’s why many insurance companies now provide treatment cost estimators which provide an easy way to see how much certain procedures and services will cost before a visit to a provider. Armed with this information, employees can make cost effective choices and more informed decisions.

Knowing the costs upfront is important due to their responsibility for paying a portion of their health care costs. And it’s helpful for budgeting aspects of their health benefits and health insurance plans, such as health savings accounts and flexible spending accounts, or for seeing how quickly they may reach their deductible and coinsurance limits.

Employees will need to create a login to their insurance company plan to access these tools. Also, it is important to note that some carriers’ sites display rates billed by the providers and others display the contracted, negotiated rates for in-network providers.

As of this posting, Medical Mutual, Aetna, and United HealthCare use the negotiated rates in their illustrations. However, Anthem uses only the rates billed by the provider, which may not provide an accurate picture to employees about their actual costs.

PPACA: What Will the Supreme Court Decide?

In late March the Supreme Court took the somewhat unusual step of setting aside three days on its calendar just to hear the various aspects of the Constitutional challenge to the Patient Protection And Affordable Care Act. The schedule affirms the universal expectation that the court will issue a ruling on the healthcare law in June, at the height of the 2012 campaign. The Supreme Court sessions began with one hour of arguments on whether it can reach a decision on the reform law before 2014.

There is a possibility that a separate federal law will prevent the courts from ruling until the law’s individual mandate has taken effect. The justices then heard two hours of arguments on the core question of whether the mandate is unconstitutional. And, finally, the court heard two and half hours of arguments on two issues: how much, if any, of the law’s other provisions can be upheld if the mandate is unconstitutional, and whether the health law’s Medicaid expansion is constitutional. There hasn’t been another case in recent memory that’s been argued on this kind of schedule. It no doubt reflects the Court’s own recognition of the complexity and importance of the issues involved.

SBC: Summary of Benefits and Coverage

The Departments of Health and Human Services, Labor, and Treasury, have issued the final regulations for the Summary of Benefits and Coverage. To help consumers better understand and compare health plans, insurers and group health plans are required to provide a new, uniform way to show benefits and define health care industry terms. The effective date for providing the SBC begins on September 23, 2012. Of course, the Supreme Court decision could affect this requirement.

The Signed Waiver: Important Protection

Most employers have some people in their workforce that do not need or want benefits for various reasons. Much of the time it is because they are covered by their spouse’s health insurance plan; although, other reasons do exist.

If your company has employees that are eligible to participate in the health insurance plan but have chosen not to for any reason, we suggest that you have them sign a “waiver of participation” form. This form is generally provided by your insurance carrier and normally is required to be completed by non-participating employees.

The signed waiver is your only protection against allegations that you did not offer coverage to an employee. The question of whether or not you allowed the employee to participate can easily be proven if you have a waiver that has been signed by the employee. Of course, this is not an allegation that comes up often. When it does, it is usually because there are outstanding claims and no insurance to cover them. This is a liability that most employers are not interested in self-insuring. A properly signed waiver is the best protection against this happening to your company.

From Wikipedia, “A true duopoly (from Greek duo δύο (two) + polein πωλεῖν (to sell)) is a specific type of oligopoly where only two producers exist in one market. In reality, this definition is generally used where only two firms have dominant control over a market. In the field of industrial organization, it is the most commonly studied form of oligopoly due to its simplicity.”

The merger of ESI and Medco essentially creates a duopoly.  Combined with CVS/Caremark, the nation’s second largest PBM, the two companies account for 73% of all prescriptions dispensed in the USA. Pharmaceutical manufacturers eager to place expensive brand prescription medications onto PBM formularies will experience more pressure from ESI to increase rebates and lower prices.  

All full-time and part-time employees are counted when determining if an employer had at least twenty employees in the previous calendar year. Part-time employees are counted as fractions of full-time employees based on the number of hours worked by full-time employees in that business. For example, if a full-time employee normally works a 6-hour day, then two part-time employees working three hours a day equal one full-time employee. Additional guidance and rules apply.

— Claim Problems —

Insurance carrier claim processors all too often look for reasons to deny a claim. At TransparentRx the mindset is different. We look for ways to get claims paid; thereby, satisfying your employees with the outcome. We don’t win every dispute, but we are successful much of the time. We encourage you or your employees to contact your broker if you’re experiencing claim difficulties.

— Dropping Coverage in Anticipation of Divorce —

Q: If an employee drops coverage on his spouse during open enrollment and the reason he is dropping her is in anticipation of a divorce, what are the requirements of the plan offering her COBRA coverage? Are there employer obligations regarding dropping the spouse’s coverage?

A: Yes. If coverage is reduced or eliminated in anticipation of a COBRA qualifying event, and the individual whose coverage was previously terminated or reduced is considered eligible for COBRA at least as of the qualifying event, the spouse must be offered the coverage, effective at least from the date of the qualifying event, which in this case is the divorce.

The final COBRA rules note that if an employee cancels a spouse’s coverage in anticipation of divorce or legal separation, “Upon receiving notice of divorce or legal separation, a plan is required to make COBRA continuation coverage available, effective on the date of the divorce or legal separation (but not for any period before the date of the divorce or legal separation).

— Small Business Health Care Tax Credits —

TransparentRx thinks it is important for employers to study and understand this section of the code, since some planning opportunities exist that could help them qualify for the maximum credit available. The availability of the Small Employer Tax Credit may encourage some employers to proceed with additional layoffs or terminations and to halt any plans to add employees in order to maximize their tax credit.

Below is a link to the IRS Website regarding the Small Business Tax Credit:
http://www.irs.gov/newsroom/article/0,,id=220839,00.html

In most RFP processes conducted by brokers or HR generalist consultants, they simply send out the request, get the top three bids and ask you, the payor, to select the vendor with the lowest price points.  The big problem here is that in most cases the price points for which your decision is based are often perceived and not real.  In fact the prices are often trivial!  As a payor your questions should be…

There are thousands of insurance sales people in this country. All can sell health insurance products and services to your firm. With that number of “suppliers” to choose from, how do you select the best organization to which you will entrust your employee benefits?

Be assured, TransparentRx, LLC is committed to customer service for our clients and the employees of our clients. Competitors have said, “When it comes to service, we are just like TransparentRx.” We are proud of the comparison but encourage you to dig a little deeper.

How should you evaluate the service attitude of one insurance agency vs. another? Open-ended questions are one of the best ways to get an in-depth look at someone’s service attitude. Some questions you might ask:

• What is the best way for my employee to resolve a claim problem?

• Are employees encouraged to call the agency for personal assistance or to call the insurance company themselves?

• What is the “problem resolution process” in your agency?

• Tell me about your staff.

• One person can only do so much; depth of staff is critical to an agency’s “service attitude”. What is your “commitment to service”?

• Is it written, verbal, or off the cuff? A written Commitment to Clients is one benchmark that an agency takes service seriously.

• Can I have a copy of your mission statement?

• Does the agency mission statement talk about growth and new sales or… focus on an attitude of service?

• What is your hiring process for service personnel?

• How do they uncover the “service attitude” of prospective employees… interviews, personality testing, references, or has it not been thought out?

• What do I do if I have a question about COBRA?

Insurers are able to enforce contractual provisions and enforcement could include cancellation of coverage. Is it possible that insurers have begun an effort to become more profitable by cancelling high risk groups that do not abide by all of the agreed upon contractual language? Two popular insurance companies have recently begun performing “eligibility audits” in an effort to determine if contract terms are being honored by employers. It may be a coincidence that the groups chosen for audit were groups known to have high claims and who were unprofitable for the insurer.

One insurance company sent a letter to the employer asking for a great deal of confidential payroll information. Normally the broker would be copied on such a communication; however, this was not the case in this instance. The letter stated that coverage would be cancelled if the requested information wasn’t received by a specific date. The business owner intended to provide the requested information but misplaced the letter by mistake. Several days after the deadline, a cancellation letter was received from the insurer. There was no follow up letter or second request sent. Health insurance coverage was cancelled for 23 employees and families, many of whom have serious medical conditions. While this may be an isolated incident, it may also be the start of a new tactic insurers are using to deal with some of the more difficult regulations they face. Time will tell.

The 51-500 employee market is somewhat different in that there are no rate caps to which carriers must abide. There is no need for a carrier to cancel a contract like in the smaller case market. Carriers simply raise rates to the breaking point for an employer. The employer will change carriers or dramatically modify benefits. Either way, the carriers profitability problem gets resolved.

The lesson to be learned is that informational requests by your insurer must be taken seriously and acted upon promptly in order to protect you and your employees from a similar outcome. Act on the request immediately by bringing your broker/consultant into the loop right away. They’ll help you navigate through in the “world of health insurance.”

Does your company provide insured short and long-term disability benefits? Have you updated the insurance company on the earnings of your employees recently? Do you increase the maximum benefits periodically to provide adequate coverage for your higher paid employees?

In the rush to get products out the door and to pay the bills, reporting salary increases to your carrier may not be a very high priority. Reporting salary increases when they occur or at least annually assures that maximum benefits will be paid to a disabled employee. This will also eliminate retroactive premium requests from the carrier.

The value of rigorous and regular eligibility audits has continued to prove itself to TransparentRx throughout the years. An eligibility audit is simply verifying that all employees and dependents associated with your company are enrolled or not enrolled appropriately in your benefit plans.

The audit can save money now and it can reduce liability for an employer. Saving money now refers to premium dollars being spent on dependents that should not be covered on your plan. The dependent may be ineligible according to the terms of your contract or the employee may no longer desire coverage for the dependent. The audit may also uncover situations where an employee is not paying the correct contributions for coverage elected. Insurance carriers are very strict about refunding premiums for employees or dependents that were enrolled in error, yet a mistake can result in thousands of dollars in overpaid premiums.

There is a great deal of risk shifted to an employer when non-eligible individuals are on the health insurance plan. It is a common belief that if an employer is paying the premium for someone, they are covered for medical expenses up to the policy limits. This is not the case. Individuals are covered if they meet the eligibility requirements of the plan. Frequently, small claims never get challenged. Inappropriate enrollment is most often discovered when there is large claims to be paid. In that case, the insurer can retroactively terminate someone and not be held responsible for the claims. If this happens, fingers most often point to the offending employer for payment of the claim.

The solution is a regular enrollment audit that compares an employer’s desired coverage with the actual enrollment with consideration for insurance company eligibility rules. Twice yearly is not too often and the process gets easier each time it is done. Of course the audit should look at payroll records to be certain the correct deductions are being charged.

Average Wholesale Price (AWP) – A published suggested wholesale price for a drug, based on the average cost of the drug to the pharmacy. AWP is often used by pharmacies to price prescription drugs.

Benefit Administration – The administration of drug benefit designs. It includes setting up and maintaining the drug coverage and exclusions, setting limits on drug coverages, and defining member cost sharing requirements.

Capitated Contract – A very rare contract among PBMs. It is used when a PBM agrees to assume financial risk for a client’s drug spending. Capitation is a set dollar amount, established by analysis of pharmacy claims data, used to cover the prescription costs for a member, usually set at a per member per month rate (PMPM).

Claims Adjudication – The online processing of a prescription drug claim. Most claims are submitted electronically at the point of service (the retail or mail pharmacy).

Client – A MCO, employer, or insurer that contracts with a PBM to administer their drug benefits and cost control programs.

Co-pay – A fixed dollar amount paid for every prescription.

Co-insurance – The fixed percentage members pay of the cost of each prescription.

Deductible – A specific annual dollar amount that a member must pay out-of-pocket for prescription drugs before the drug benefit program begins.

Disease Management Programs – Programs developed by PBMs to identify and categorize patients (especially those with chronic conditions) and to direct these patients towards a specific treatment protocol.

Fee-for-Services Contract – The most common pricing arrangement PBMs have with their clients. Under the contract, PBMs are paid for the administrative services they provide, and they do not assume the risk for the cost of the drugs dispensed.

Formulary – An approved list of branded (and generic) drugs developed by the PBM, or the client.

• Open Formulary – A list of recommended drugs. Under this structure all drugs are reimbursed irrespective of formulary status. However, a client’s plan design may exclude certain drugs (OTC, cosmetic, and lifestyle drugs).

• Incented Formulary – An incented formulary applies differential co-pays or other financial incentives to influence patients to use, pharmacists to dispense, and physicians to write formulary products.

• Closed Formulary – A closed formulary limits reimbursement to those drugs listed on the formulary. Non-formulary drugs are reimbursed if the drugs are determined to be medically necessary, and the member has received prior authorization.

Health Care Financing Administration (HCFA) – the federal agency that administers Medicare, Medicaid, and the State Children’s Health Insurance Program (SCHIP).

Ingredient Cost – The cost to the pharmacy for dispensed drugs (AWP – discount %).

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

Mail Pharmacy – Mail pharmacies dispense a 90-day supply of drugs through the mail; typically used for chronic conditions. Most pharmacy benefit plans offer a mail pharmacy service as a way to promote cost savings and improve access.

Managed Care Organization (MCOs) – A broad term encompassing a variety of healthcare delivery systems utilizing group practice and providing an alternative to fee-for-service health plans. The primary goal of a MCO is to create incentives to use a prepaid and organized healthcare system that serves a defined population.

Manufacturer – A company that manufacturers branded and/or generic pharmaceuticals.

Maximum Allowable Cost (MAC) – The price basis for generic drugs which is typically 50–60% below AWP. PBMs can either set the MAC prices themselves, or use the MAC prices set by HCFA for Medicaid beneficiaries.

Member – A covered individual within a health plan.

PEPM – Per employee per month.

PMPM – Per member per month; in an employer plan includes employees and their covered dependents.

Pharmacy Benefit Manager/Management (PBM) – A company providing administrative and clinical services through a complex system that includes retail pharmacies, manufacturers, clients, physicians, and members. These companies administer drug benefits and drug cost control programs for their clients, and secure substantial discounts from retail pharmacies and drug manufacturers. PBMs establish and maintain large pharmacy networks with chain and independent pharmacies. Also, PBMs contract with manufacturers of branded products to receive rebates and administrative fees.

Pharmacy Network – Specifies which pharmacies are approved for members, and includes retail, mail, and in some cases specialty pharmacies.

Prior Authorization – A prior approval process that allows prescription drugs to be dispensed to members only when specific conditions have been met.

Shared Savings Contract – A contract between a PBM and a client that provides incentives for both sides to collaborate and run the pharmacy benefit effectively and to share in the overall cost savings.

Therapeutic Substitution Programs – Typically operated in mail pharmacies to encourage physicians and patients to switch from the drug prescribed to lower cost, comparable drugs. Substitution requires physician and typically member permission.

Rebates – Paid by manufacturers to PBMs for the sale of branded drugs to PBM members.

Usual and Customary (U&C) – The price pharmacies charge to cash paying customers for prescription drugs.

Utilization Management Programs – Programs designed to lower drug costs and utilization and to encourage the use of generics or preferred products. These programs include services such as prior authorization, drug utilization review (concurrent and retrospective), academic detailing programs, and patient education.

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

PBMs commonly operate on behalf of employers, insurance companies, and unions; they are also sometimes referred to as “third-party payors.” The original purpose of PBMs was straightforward: issue drug cards for easy ID and account tracking and offer their customer groups cost-effective services as well as reliable claims information.

Over time, however, PBMs have evolved into much more complex organizations. PBMs now take advantage of various strategies associated with rapid growth, including large-scale “block purchases” of drugs and medical products that dramatically lower their wholesale costs — even as PBM fees have consistently increased for customers. Some PBM practices are, in fact, the subject of lawsuits or federal and state regulatory investigations.

So how can you, as a benefit manager, make the best pharmacy decision for your employees?  How can you have confidence that your company is receiving optimum PBM value and service?  What key questions should you ask your current or potential PBM—or your health insurer contracting with a PBM?  The following 10 questions are designed to help you and other Benefit Managers select the best PBM for your organizations.

1) Do you use the same average wholesale price (AWP) and maximum allowable cost (MAC) in calculating price to clients and payments to pharmacies?

Some PBMs realize hidden profits by employing a practice known as “differential or spread pricing.” Differential pricing is when a PBM establishes a discount off the average wholesale price (AWP) for the individual employee filling a prescription, but establishes a different AWP discount for retailers.

Here’s an example of differential pricing in action:

Your employee or group member pays AWP minus 15%
PBM pays retailer AWP minus 18%
PBM pockets the 3% differential

Although PBM revenues derived from differential pricing can run between $5 and $8 depending on the type of program served, typical PBM disclosed fees hover at $1 per prescription. While differential pricing is a common business practice, PBMs should disclose the differential to you or your health insurer.

If you have a plan governed by ERISA, you should keep in mind that the U.S. Department of Labor requires full disclosure of all compensation, fees, and income from a PBM that acts in a fiduciary capacity as an administrator and/or claims payor for an employer with a benefits plan.

Recommendation: Ask to see your PBM’s contract with network pharmacies (including large chains) and compare to the PBM’s contract with your organization. The reimbursement rates should be the same on both contracts for both AWP and MAC.

2) Do you participate in rebates from drug manufacturers?

PBMs often receive rebates from drug manufacturers in return for placing products on formularies and for working to increase sales volume for these drugs (rebates can range from $.50 to $2.50 per claim). Some employers permit PBMs to keep 100 percent of rebates in exchange for lower administrative fees. Alternatively, some employers have agreed to a sharing arrangement, typically 50/50.

Recommendation: Require your PBM to disclose the total amount of rebate dollars collected as a result of the business you represent to the PBM—and ask for supporting documentation that explains how rebate revenue is calculated.  Some PBMs reclassify rebates using categories such as education grants, research, advertising, promotion, access fees, formulary management fees, and data collection fees.  You are entitled to 100% of all rebates, regardless of reclassification, so be sure to get every penny and to spell this out in your contract.

3) Does your PBM offer full transparency and 100% pass-through?

Many PBMs offer “transparency” and they will even tell you how they make money by collecting network spread, mail order operations, or in rebates, but unless you are very experienced in the industry; it is difficult to ascertain the real amounts of money involved.

“Transparency and PASS THROUGH” means a PBM will collect an administrative fee for processing and managing the pharmacy benefit, but that is the only source of revenue.  Rebates are passed back 100 percent to the payor and there is no network spread. (These can be audited and validated very easily.)

In many cases, these newer model PBMs are not as big as the major players in the industry, but because of the type of model they operate, they can actually save the client money compared to a traditional model PBM due to the increased transparency and reduced alternate revenue sources other PBMs maintain.  Even the fact that they are smaller and have less perceived buying power is offset by the model design

Recommendation: Hire a consultant to help manage the PBM jungle, make sure that consultant is also transparent. That is, ask them if they have any ties to any particular PBM and ask them their philosophy regarding transparency in PBM operations.

4) Are your mail-order and retail MAC lists identical?

PBM operations have a lot of moving parts, and many processes that can be manipulated either intentionally or not.  For example, a PBM may agree to use a MAC (Maximum Allowable Cost) program for generic drugs, but neglect to tell the payer that they have multiple MACs that allow for additional margin to the PBM that may not be in the best interest of the payer.  The PBM may also use the MAC for their retail network, but not for their mail order operations.

Recommendation: Ask for a copy of the PBMs price lists (pharmacy and sponsor) and get regular updates.  Conduct periodic comparisons of actual claims cost to the PBMs price list.  If there is a difference in price then spreads or other hidden costs are likely the issues. It is red flag when a PBM does not offer full audit rights or access to all price lists.

5) Does your formulary limit drugs that will be covered?

A formulary is a list of “preferred drugs that pharmaceutical manufacturers discount to employers and other groups in exchange for volume usage.” The most effective formularies optimize and balance quality, effectiveness, and costs.

Check to see if your health plan has to pre-approve a medication before plan members can get their prescription filled. Many plans require physicians to get prior authorization of medications before the plan will cover the drug. That means physicians or pharmacists must call the health plan or PBM for permission to write or fill certain prescriptions.  Some plans also require members to try a less expensive medicine first, before they will cover the one recommended by the member’s physician.

Recommendation: Make sure that any switching of drugs is constructed to save you money and
not the PBM. Check with your plan to understand its authorization process so members are not
surprised when they arrive at the pharmacy. And, be sure to learn how to appeal requirements
and decisions when your members have complaints.

6) How often do you change your formulary?

In most states, even though medications may be covered when the health plan is selected, a PBM may change its list (both prices and availability) of approved medicines at any time throughout the year. If a medication is removed from the formulary without prior notice, the individual patient must either pay out-of-pocket or accept a medication that the PBM prefers.

Recommendation: Check with your PBM for policies related to formulary changes. Will you receive notice of formulary changes in writing?  If not, ask for notification.

7) How are co-payments set?

Most health plans require a co-payment for each prescription. Some plans have a single co-payment — for example, $10 for any prescription. Other plans have different levels of copayments for different medications, a system known as “tiered co-pay.” A PBM can shift medications from tier to tier at any time, leading to potentially unpleasant surprises for employees presenting prescriptions at pharmacies.

Recommendation: Ask about how you and plan members will be notified when the PBM makes a tiered co-pay change for a medication.

8) Do you offer performance guarantees?

Performance measurement is a key function for clients as they assess their ongoing relationship with their PBM. Traditionally, performance measurement is divided into the following two categories: Cost and utilization; and PBM service performance.

Cost and utilization performance measurement includes such metrics as the number of prescriptions dispensed per member, average ingredient cost per prescription and per member, generic use rates, and rebates. Cost and utilization results may vary significantly by client based on the client’s demographics and the client’s overall benefit plan design.

Conversely, PBM service performance measurements are more uniform. Clients have established a series of benchmarks and service guarantees to measure the overall service performance of a PBM. Many of the service guarantees were derived from the guarantees used by medical claims administrators. Service guarantees deal primarily with the administrative aspects of a PBM’s performance, as this is the main service provided by the PBM.

Since PBMs do not manufacturer, prescribe and dispense drugs (with the exception of mail order), the service performance measurements are the main “quality” measurement for a PBM.

Recommendation: One of the best means of tracking overall PBM performance is by conducting annual customer satisfaction surveys. In almost all cases, the monitoring of performance measures is performed and paid for by the PBM.  Another feature that all clients should demand is a market check at specified intervals during a typical three year contract – say, every year or at the 18 month mark – such that there is an opportunity to review and renegotiate some of the terms if market conditions change.

9) Can you provide a detailed explanation of your fee schedule and specifically the cost of clinical programs?

Be sure to compare “apples to apples” when evaluating a financial proposal from a PBM.  Inexpensive claims processing fees may be less attractive if you are “nickel and dimed” on everything else. Clinical programs are an area where fees vary widely.

For example, a prior authorization (PA) program establishes protocols for prior approvals of expensive, nonformulary drugs. A PA program is one tool, among many, that keep costs under control. However, PA program fees vary widely, ranging from $2 to $40 per PA.

Recommendation: Ask for detailed disclosure and explanation of a PBM’s fee schedule. If policies related to prior authorization systems are not clearly explained — ask.

10) What is your policy on selling pharmacy data?

In the business of health care, information equals revenue.  Every drug manufacturer would like to know about your plan members’ demographics and utilization patterns.  You have the right to demand that your company’s proprietary information not be sold by your PBM to the highest bidder.  And, that all PBM practices are in compliance with the privacy regulations established under the Health Care Portability and Accountability Act (HIPAA).

Recommendation: Ask the PBM to include a paragraph covering the sale of data in your contract. If you have no objection to aggregate data being sold, you should still require disclosure of the sales. Also consider the value of your company’s data and whether or not to ask for some form of compensation from the PBM.

All of the above questions are important points to keep in mind the next time you have the opportunity to comparison shop for a PBM. Just remember that it is only after the layers of each offering are peeled back will the PBM representing the best fit be determined.

The larger spreads generally take place with generic medications.  This is due in part to much smaller COG (cost of goods) and larger profit margins attained from generic compared to brand medications. Think about it for a second.  A generic medication may have fifteen different manufacturers (multi-source) all competing for the same purchaser while a brand product will have in most instances only one manufacturer (single-source).  This, ultimately, leads to lower costs for generic medications and much higher costs for brand medications.

Supply-side economics tell you that much more money is too be had from the sell of generic medications vs. brand medications.  Don’t be upset with your local pharmacist due to the high price of brand medications.  He or she has very little control, to the downside, on the price of these products.

Small to medium-sized businesses are most often the victims of spreads.  Larger companies often maintain a staff (which may include a seasoned pharmacist or two) dedicated to thwarting the efforts of any PBM attempting to hide cash flows.  Make no mistake about it; spreads are an opportunity cost and hidden cash flow.  I urge you to read the pilot study conducted by American Pharmacists Association.  Here is the abstract from this study.

Objective: To document the difference between what pharmacy benefits management companies (PBMs) charge employers and what they pay dispensing pharmacies for the drug ingredient portion of prescription transactions (the “spread”).

Design: Descriptive, cross-sectional study.

Participants: Two large employer groups, each of which used a different PBM, and six independent community pharmacies participating in these plans during 2002.

Interventions: Two sets of financial records issued by each of two PBMs were reviewed retrospectively, including 129 line-item prescription transactions billed to the employer and the line-item transaction information that accompanies the PBM payment to the dispensing pharmacy.

Main Outcome Measure: Spread between drug ingredient cost billed to the employer by the PBM and drug ingredient cost paid to the dispensing pharmacy by the PBM for brand name versus generic drug products.

Results: For both PBMs, the mean (± SD) spread was $12.29 ± 27.93 per prescription, with a range of –$1.67 to $201.65. Considering all 129 transactions, the mean spreads for brand name and generic medications were significantly different from one another, with mean (± SD) spreads of $4.65 ± 10.47 and $23.45 ± 39.47 per prescription, respectively. The two PBMs differed significantly in their spreads for brand name drugs ($3.20 ± 2.85 and $5.93 ± 14.12), but the spreads for generic products did not achieve statistical significance in absolute dollars ($10.83 ± 13.58 and $31.74 ± 48.11) because of their greater variation (as reflected in the larger standard deviations). However, the percentages difference for generic products differed significantly.

Conclusion: This pilot study indicates the possibility of substantial and widely varying differences in the spread and spread percentage between PBMs for brand name and generic medications. A more transparent business model for the PBM industry could produce better relations with PBM clients and business partners, including community pharmacies.

Individuals applying for coverage under the high risk pools run by the federal government in 23 states and the District of Columbia will just have to show a doctor’s note that says they have a pre-existing medical condition. Is there any question about the abuse this leads to from individuals that do not want to pay for coverage until they become ill?

Premiums will drop as much as 40 percent in 17 of the states plus the District where the federally run plans operate, bringing high-risk premiums in those states closer to the rates that can be found in the individual market. The premium costs and the requirement to prove an inability to find insurance were two obstacles that have kept the high-risk pool enrollment to below 20,000 people when the promise was that 500,000 would enroll.

There was a time when many experts believed the $5 billion set aside for high-risk pools by the health reform law wouldn’t be enough to meet demand. The pools were designed to be an early carrot in the health law that would give people coverage options until 2014, when insurance carriers will no longer be able to discriminate based on pre-existing conditions.

TransparentRx, LLC has over ten years experience in the health insurance industry. We have observed many carriers try to gain market share. Experience demonstrates that the quickest way to failure for an insurer is to eliminate all barriers to entry and lower prices. If HHS were faced with the same scrutiny by state insurance departments as insurance companies, they would be served with Cease and Desist Orders for the way the risk pools are being managed.

On the other hand, insurance companies do not have the deep pockets of the American Taxpayer to fall back on.  This, in turn, leads to higher costs for plan sponsors.