Author: Tyrone Squires, MBA, CPBS

This author has written 1330 articles

Tip of the Week: Drugmakers circumvent health plan sponsor benefit designs, at the switch, to get high-cost brand drugs dispensed

Why aren’t more people up in arms about this? Brand drugmakers are circumventing pharmacy benefit plan designs by offering eVouchers or electronic vouchers for expensive drugs at the “Switch.” The switch is what routes the third-party prescription claim to the PBM or health plan associated with the prescription. Within seconds, the script leaves the pharmacy, goes to the switch and then is received at the relevant PBM.


When the benefit design has soft UM or no utilization management protocols, such as mandatory generic enforcement, it allows drugmakers to bypass a tier 1 drug for a tier 2-4 drug or even worse a non-formulary drug, with eVouchers (see process flow diagram below). The two largest switch companies are RelayHealth and Change Healthcare. As Relay Health tells the story, its electronic voucher program is a Win-Win-Win solution:
  • Doctors “set aside concerns over costs”
  • “Patients benefit from lower copays” and “increased adherence”
  • Manufacturers benefit from increased “scripts written”, “the likelihood patients will fill and adhere to them” and “increased brand loyalty”
But what about you the health plan sponsor? You are conveniently left out of the equation even though you cover most of the cost. I teach in our CPBS Certification course how plan sponsors fund the entire USA prescription drug system but know the least about how it works. Simply put, it is your checkbook they are after. The financial impact of switch operators’ eVoucher programs to health plan sponsors is significant and growing with each passing day.

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There are two ways to prevent the scenario above from happening:

(1) PBM puts language into its contract, with the Switch company, preventing the action.
(2) Benefit design maximizes the drug utilization management toolkit including step therapy and mandatory generic enforcement programs.

Number two is sticky as many plan sponsors are hellbent on employees getting the drug they want without any scrutiny (i.e. step therapy). I don’t agree but it’s not my checkbook. The point is to make people happy through better outcomes not for the sake of avoiding the pain that comes with running an efficient health plan. In a sense, drugmakers, and non-fiduciary PBMs for that matter, are leveraging HR’s desire to keep employees “happy.”

For TransparentRx the choice is simple, either you want an efficient pharmacy benefit program or you don’t. If you [health plan sponsors] don’t want an efficient pharmacy benefit program then expect to pay $1000 for a drug when a $100 drug would have provided the same level of efficacy, for example. eVouchers, especially when supported with direct-to-consumer TV ads for high-cost brand drugs and soft utilization management protocols, are an expensive proposition for health plan sponsors yet lucrative one for brand drugmakers.

Ohio awards contract worth billions to the same company it accused of fraud and was later paid $88 million as a result

Ohio is again in business with a company that only recently it was accusing of massive fraud. The state’s leaders seem reluctant to explain why. Two months ago, Ohio Attorney General Dave Yost announced that Centene, the largest Medicaid managed-care provider in the United States, would pay Ohio $88.3 million to settle a lawsuit claiming that Centene had defrauded taxpayers of tens of millions of dollars. 

In a regulatory filing, the company said its overall settlement of those and expected fraud claims was much bigger than that. It set aside $1.3 billion to settle such claims across the country, the filing said. An analysis commissioned by the Ohio Department of Medicaid showed that in 2017, drug middlemen owned by Centene was charging the state $20 million for services that it was already paying CVS for. It’s a claim they both denied.

Tyrone’s Commentary:

There are probably details the public is not privy to, but lets assume for a second that isn’t the case. If I had to do it all over again, I would pick up golf. It seems relationships matter more than results for some.

The suit AG Yost filed against Centene in March made a similar allegation. It said that Buckeye had defrauded taxpayers of tens of millions of dollars by working through a chain of middlemen to overcharge for prescription drugs. On Friday — a day when government entities are known to put out news they want to bury — Medicaid issued a brief press release. It touted the news that Centene’s Buckeye would become the state’s seventh managed care provider by saying it “will give customers more options.”

It didn’t make any mention of fraud; it just said the lawsuit was settled, so it’s time to get back into business with Centene.

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10 Definitions, Related to Prescription Drug Prices, All Purchasers of PBM Services Should Know

The first half of 2021 has seen more brand-name drug list price increases than all of 2020, according to an analysis by 46Brooklyn, a nonprofit drug research firm. The increases reverse the downward trend in brand name drug price increase frequency that’s been observed over the last decade, 46Brooklyn reported. Through July 10, there were 78 list price increases of brand-name drugs, a number nearly equal to the full amount of July price increases occurring in the last three years. 

But despite 2021 having more list price increases than 2020, there is no change in the weighted average brand name drug price increase. This suggests that though increases are happening more frequently than last year, the size of the increases is comparable to those over the last several years, 46Brooklyn reported. 

The price increases in July 2021 have a modest weighted average increase of 2 percent, representing about $1.3 billion in prior year Medicaid expenditures. Net prices have been declining despite list price increases, according to 46Brooklyn. For more on this, check out the Gross-to-Net Bubble update. 

Below are ten definitions, related to prescription drug prices, all purchasers of PBM services should know.

  • Acquisition Cost is defined as the invoice price to the pharmacy for a prescription drug dispensed to a patient, minus the amount of all discounts and other cost reductions attributable to such dispensed drug.

  • Average Manufacturer Price (AMP) is the average price paid to the manufacturer for the drug in the United States by wholesalers for drugs distributed to retail community pharmacies and by retail community pharmacies that purchase drugs directly from the manufacturer. The health reform law excludes payments and rebates or discounts provided to certain providers and payers from the calculation of AMP.  
  • Average Sales Price (ASP) is a manufacturer’s unit sales of a drug to all purchasers in the United States in a calendar quarter divided by the total number of drug units sold by the manufacturer in that same quarter. The ASP is net of any price concessions such as volume, prompt pay, and cash discounts; free goods contingent on purchase requirements; chargebacks; and rebates other than those obtained through the Medicaid drug rebate program. Certain sales are exempt from the calculation of ASP, including sales at a nominal charge.

  • Average Wholesale Price (AWP) is not based on actual transactional, marketplace price data.  Despite its name and its sometime use as a price index, the published AWP is not an average of actual wholesale prices. It is not intended to represent, and cannot be assumed to reflect, actual transaction prices. A wholesaler or other direct purchaser from a pharmaceutical manufacturer may agree to sell its products to one or more of its customers at prices that on their face are effectively lower than the published AWP. AWP information does not reflect any such lower pricing that may be made available in actual purchase transactions through a variety of methods, including, but not limited to, purchase, prompt-pay or other discounts, volume or other rebates or credits, or a variety of other price reduction arrangements.

  • Direct Price (DP) is the price directly reported to AWP publishers by a manufacturer as the list price at which non-wholesalers and healthcare providers may purchase drug products from that manufacturer. These publishers generally do not receive a reported DP for drugs that are sold by a manufacturer exclusively through wholesalers, although in some cases both a DP and a WAC may be provided at the manufacturer’s discretion. Like AWP, DP does not represent an actual sales price in any single transaction or group of transactions between a manufacturer and a non-wholesaler or healthcare provider, as any manufacturer may agree to sell its products to one or more customers at a lower price through any number of methods, including, but not limited to, discounts, rebates, credits or other net price reduction arrangements.

  • Federal Supply Schedule (FSS) are prices paid to manufacturers by the VA, other federal agencies, and certain other entities, such as Indian tribal governments, are set by the Federal Supply Schedule (FSS). Under the Veterans Health Care Act of 1992, manufacturers must make drugs available to covered entities at the FSS price as a condition of eligibility for Medicaid reimbursement.  FSS prices are negotiated with manufacturers by the VA.15 In general, the FSS price may be no higher than the lowest contractual price charged by the manufacturer to any non-federal purchaser under similar terms and conditions. In order to determine this price, manufacturers supply the VA with information on price discounts and rebates offered to different customers and the terms and conditions involved. Under certain conditions, the VA may accept an FSS price that is higher than the price offered to some non-federal customers. According to the GAO, average FSS prices are more than 50 percent below the non-federal average manufacturer’s price.
  • Ingredient Cost is the cost to the pharmacy for dispensed drugs.
  • Maximum Allowable Cost (MAC) list generally refers to a payer or PBM‐generated list of products that includes the upper limit or maximum amount that a plan will pay for generic drugs and brand name drugs that have generic versions available (multi‐source brands). Essentially, no two MAC lists are alike and each PBM picks and chooses products for their MAC lists, using different criteria to derive and apply prices to the list.  

  • Suggested Wholesale Price (SWP) is the price that a manufacturer suggests wholesalers charge when selling the manufacturer’s drug to the wholesaler’s customers, as reported by the manufacturer. The SWP does not necessarily represent the actual sales price used by a wholesaler in any specific transaction or group of transactions with its own customers. Wholesalers determine the actual prices at which they sell drug products to their respective customers, based on a variety of competitive, customer and market factors.

  • Wholesale Acquisition Cost (WAC) is the price directly reported to publishers, like Wolters Kluwer Health, by a manufacturer as the list price at which wholesalers may purchase drug products from that manufacturer.  WAC does not represent an actual sales price in any single transaction or group of transactions between a manufacturer and a wholesaler, as any manufacturer may agree to sell its products to one or more customers at a lower price through any number of methods, including, but not limited to, discounts, rebates, credits or other net price reduction arrangements.
Education is key to use of lowest net cost drugs in pharmacy benefit plans. Only the most sophisticated purchasers of PBM services will have the knowledge and confidence to bind lowest net costs for prescription drugs into contract language and benefit design. Hence, your competitive advantage includes executing good analysis of the correct information then deciding what all of this suggests for your organization. 

Tip of the Week: The health plan sponsor hiring a PBM always has the final say on contract terms

Many purchasers of PBM services or their advisers select the PBM vendor who puts the “lowest price” on the table. Lowest price involves several variables including admin fees, rebate guarantees, AWP discounts and most important contract language. The problem is plan sponsors are putting a premium on the “numbers” and largely discounting the contract language. 

The Pharmaceutical Care Management Association (PCMA) is an American national trade association representing pharmacy benefit managers. Greg Lopes, an Associate Vice President of the Pharmaceutical Care Management Association, said “The health plan sponsor hiring a PBM always has the final say on contract terms.” Seasoned executives or brokers can be seduced into placing more emphasis on the spreadsheet instead of the contract language. 

For example, price quotes are simply an estimate of what the plan sponsor would have spent had the historical utilization matched that of the proposing PBM (a lot in this sentence). Furthermore, the future actual cost is unknown. As a result, the plan sponsor’s PBM contract is the most important tool to address the actual level of spend – not cost projections.

Following up on a newspaper investigation, The Ohio Department of Medicaid commissioned an analysis of its 2017 drug reimbursement data and found that two PBMs billed the state almost a quarter billion dollars more for generic drugs than it paid the pharmacies that dispensed them. Ohio’s Medicaid Director, Maureen Corcoran, sad this in response to a question posed by a reporter, “Have we saved the state money? That wasn’t the point. The point was transparency and so that we could continue to work on” necessary changes “in an educated way.”

I’m often asked, “Tyrone, tell me again why the proposal with the lowest cost isn’t necessarily the lowest cost?” The simple answer is the contract language sets the foundation for all of the financials – not the other way around. It is through continuous PBM education you become a more sophisticated purchaser of pharmacy benefits which inevitably leads to radical transparency in your PBM relationship(s).

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Tip of the Week: Education is the most logical and effective foundation for achieving maximum value in pharmacy benefit management (PBM) services.

Teachers, military personnel, doctors, pharmacists and even some professional athletes are tested for competency specific to their job functions. Yet, in an industry where over $400 billion changes hands annually the folks making purchasing decisions don’t have to prove competency specific to pharmacy benefits management. It’s really quite simple, PBM competency (mastery) = lower costs = better patient outcomes.


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Expand your PBM knowledge beyond a functional role and understand exactly how each domain works together within the pharmacy distribution and reimbursement system. Education is the most logical and effective foundation for achieving maximum value in pharmacy benefit management (PBM) services. Assessing transparency will be more effectively done by a trained eye.

The Untold Truth: How Pharmacy Benefit Managers Make Money [Free Webinar]

How many businesses do you know want to cut their revenues in half? That’s why traditional pharmacy benefit managers don’t offer a fiduciary standard 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
  • Basic to intermediate level PBM terminologies
  • Specialty pharmacy cost-containment strategies
  • Examples of drugs that you might be covering that are costing you
  • The #1 metric to measure when evaluating PBM proposals

Sincerely,
TransparentRx
Tyrone D. Squires, MBA  
10845 Griffith Peak Drive, Suite 200  
Las Vegas, NV 89135 
Office: (866) 499-1940
Mobile: (702) 803-4154


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.  

Tip of the Week: Non-Fiduciary PBMs Hedge Against Their Legacy Business Models

Anthem and Humana have invested nearly $140 million to form a new pharmacy benefit manager, as criticism over traditional PBMs’ operations kickstarts business at startups that promise transparency. The new venture comes as more payers begin to question the work of the “Big Three” PBMs.

  • In 2019, Anthem launched in-house PBM IngenioRx, after suing Cigna’s Express Scripts for $15 billion over allegations the company withheld savings and overcharged the insurer.
  • In April, Costco announced it was expanding its partnership with Madison, Wisc.-based Navitus Health Solutions, a PBM owned by SSM Health
  • Ohio announced it was partnering with Tysons, Va.-based Gainwell Technologies to operate its own PBM, which it expects to save the state $240 million in drug costs each year, compared with its former private operators.

Tyrone’s Commentary:

Every profession and industry has its bad actors, and ours is no different. Just because the business model of non-fiduciary PBMs has become layer upon layer of self-dealing, it is important to remember that many of our peers are doing good work within the walls of those enterprises as well. In our ongoing effort to push the industry toward radical transparency, we will continue with education as our focal point because we know there are fantastic people within the industry who can help us in our goal to raise the standard of care for purchasers of PBM services. Afterall, education is the key to getting to lowest net cost.

The insurers, Anthem and Cigna, will hold a minority stake in the new joint venture, named DomaniRx, which is being championed by SS&C Technologies. The Windsor, Conn.-based fintech company owns approximately 80% of the new business, according to a filing submitted to the U.S. Securities and Exchange Commission on July 15. 

Humana will serve as DomaniRx’s first customer. The Louisville, Ky.-based insurer currently operates its own PBM. Humana and Anthem hold a non-exclusive license to RxNova SS&C’s existing claims processing platform.

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Tip of the Week: The Specialty Drug Pipeline Will Make You Rethink Your Pharmacy Benefits Management Strategy

Employers should be aware that the new drug pipeline focuses on manufacturer investments in developing high-cost brand, specialty and orphan drugs. With more than 8,000 drugs in development, new drug launches will reach historically high levels over the next several years.

New and potentially lifesaving or life-prolonging therapies are reviewed and approved every year, but generally there are two drug pipelines to monitor: novel drugs coming to the market for the first time for any indication, and new indications for existing medications already approved by the U.S. Food and Drug Administration (FDA).
There are several recommended strategies that are proven effective for managing high-cost specialty drugs today. It begins with first understanding the financial and member disruption (i.e., employee retention/recruitment impact) goals for each employer. Then you can focus on these four key areas to ensure a holistic solution is in place to manage costs and appropriate utilization in line with both the contract and clinical perspectives:


1. Maximize contract value: Obtain the lowest net costs with radically transparent discounts and manufacturer revenue yield through an aligned formulary coupled with an unbiased analysis and independent review strategy. Easier said than done.

2. Evaluate plan design: Examine tiering, copay vs. coinsurance, HDHP vs non-HDHP; Deductibles/Out of Pocket Maximum changes, separate medical/pharmacy accumulators, network design, mail order, Dispense as Written penalties, etc., as well as the extent of each change under consideration (ex: 10% vs 20% coinsurance).
3. Eliminate wasteful spending: Remove questionable low clinical value medications from the formulary; independently review prior authorizations, suspect high-dollar claims, and drugs with the potential to be used off-label; optimize existing therapy and dosing to remedy any per-dose cost improvement opportunities; and independently verify appropriate indication and dosing for complex conditions.
4. Manufacturer assistance programs: Leverage available manufacturer-provided member incentives on specialty medications through a PBM systems-based approach, as opposed to partial carveout solutions that require manual formulary and system manipulations that generate additional risks and inefficiencies.

Tyrone’s Commentary:
Pharmaceutical manufacturers are light years ahead of plan sponsors including both public and private entities. They are keenly aware that the “free” drugs given away today are a temporary slow down of specialty drug spend, for instance. They will continue to innovate and manufacture curative pharmaceutical products. As a result, more and more people will not qualify for patient assistance and/or exhaust coupon savings programs. Many plans will see their drug spend fall back to pre-manufacturer assistance levels in 2-3 years. Specialty drugs will soon account for more than three-quarters (75%) of total drug spend wiping away early gains from manufacturer cost-saving programs. 

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Costco approach could have saved Medicare $2.6 billion in drug spending, analysis shows

Medicare spent billions more money on generic drugs for its beneficiaries than warehouse chain Costco did for the same drugs, according to an analysis published Tuesday. This overspending hit $2.6 billion in 2018, Erin Trish, associate director of the University of Southern California’s Schaeffer Center for Health Policy and Economics, and colleagues wrote in a letter to the Journal of the American Medical Association’s JAMA internal Medicine.

Figure 1: Five P’s of Decision-Making

Tyrone’s Commentary:

Purchasers of PBM services need to recognize that smaller PBMs can provide similar or better levels of service at a lower cost. Your jobs are not at risk for trying a different approach when the current strategy is severely flawed. In fact, just the opposite is true. Save your company a few million bucks and you have grounds for a pay raise and/or promotion. What drives decisions in your PBM selection process? The best leaders, with P&L responsibility, make decisions at the top of the pyramid (see figure 1). Assess yourself as a plan sponsor. 

They compared the amount Medicare pays for common generic prescriptions in its Part D prescription coverage with prices available to patients without insurance at Costco for 184 common generic drug products. “Medicare overspent by 13.2% in 2017 and 20.6% in 2018 compared with Costco member prices for these prescriptions,” they wrote. “Total overspending increased from $1.7 billion in 2017 to $2.6 billion in 2018.”

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Tip of the Week: Fiduciary Model Pharmacy Benefit Managers (PBM) are a Thing

Clayton Christensen’s business concept of “The Innovator’s Dilemma” is one of my favorite books. In it he writes about how incumbent companies lose to new business models because they are too busy protecting their older legacy business models. Non-fiduciary PBMs don’t focus on a fiduciary standard of care or radical transparency because they are too busy protecting their older, opaque business models. 


Disruptive innovations tend to be produced by outsiders and entrepreneurs in startups, rather than existing market-leading companies. The business environment of market leaders does not allow them to pursue disruptive innovations when they first arise, because they are not profitable enough at first and because their development can take scarce resources away from sustaining innovations (which are needed to compete against current competition). Small teams are more likely to create disruptive innovations than large teams. A disruptive process can take longer to develop than by the conventional approach and the risk associated to it is higher than the other more incremental or evolutionary forms of innovations, but once it is deployed in the market, it achieves a much faster penetration and higher degree of impact on the established markets.

TransparentRx is the first fiduciary model PBM in America and now another PBM, Drexi, has joined the ranks of the disruptive. From the press release, “Advanced Medical Pricing Solutions (AMPS), a pioneer in healthcare cost containment, is pleased to announce the expansion of its fiduciary duties to include Drexi, its pharmacy benefits manager (PBM) solution…The expansion makes it one of the first PBM fiduciaries in the U.S.” I like how they were careful to write “one of the first.”

We welcome the competition as it benefits the market – plan sponsors, patients and other stakeholders. It also makes our job easier when explaining the difference between a fiduciary PBM and one that isn’t to a potential client. I’ve not yet personally had a chance to review the AMP’s PBM service agreement so I can’t comment on whether or not the contract nomenclature is truly fiduciary in law and spirit. Here are some things employers must look out for when considering doing business with a fiduciary PBM.

1) PBM or Pharmacy Benefit Administrator (PBA) provides radical transparency

2) Any revenue currently collected by the PBM from the manufacturer or rebate aggregator is disclosed and employers receive 100% of these earned refunds (less data fees) 

3) Gives full auditing rights in PBM contracts including unrestrictive access to claims data

4) Fiduciary PBMs are substantially at risk. $100K on a $10M drug spend is not substantial

5) No exclusivity. The primary reason PBMs suggest you not carve-out is due to their own selfishness. Despite what they tell you it is not because carve-in adds more value. They only share the good it does not the harm. Caterpillar has carved-out PBM services for more than a decade with much success.

6) Elimination of spreads. In some cases, a PBM will charge the plan sponsor more than they pay the pharmacy to fill a prescription.

In business theory, a disruptive innovation is an innovation that creates a new market and value network and eventually displaces established market-leading firms, products, and alliances. I’d be worried if my wagon were hitched to a PBM holding on to old legacy business models.