This document is updated weekly, but why is it important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to health care reform. 

The costs shared below are what the 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.

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.

Note: Prices listed herein are gross thus do not account for rebates, discounts or other purchase incentives which ultimately reduces the net cost.

Any program that puts more greenbacks in patients’ pockets in this post-recession economy has to be viewed as a good one, right? Alas, it depends on the person you ask.

Devised to shoulder some of the cost burden of prescription drugs, manufacturer co-pay card programs have been tied to improved adherence rates and reduced barriers to the discounted medications. At the same time, payers — insurers and PBMs alike — are crying foul.

While some industry veterans sing the praises of co-pay assistance programs, others are eager for a more evenhanded and efficient solution that will achieve the same degree of cost savings. In fact, the co-pay card appears to be stirring the controversy pot more than ever. Indeed, the question seems to have become: What will make it boil over?

UNHAPPY PAYERS

Click to Enlarge

But after more than a decade as an industry staple, the instant-rebate tactic has come under fire. Andrew Miller, VP of operations at pharmacy benefits manager MeridianRx, has grown increasingly concerned with the damaging effects of co-pay cards on payers. Consider insured patients who have been prescribed AbbVie’s Humira for their rheumatoid arthritis at $4,000 per month. After insurance and co-insurance kick in, they’re on the hook for $1,000 a month. But wait — the manufacturer just happens to have a co-pay coupon, which reduces the cost to zero.

What’s the problem, you ask? The insurer and the PBM didn’t get the memo. After six months of taking and paying for the medication, the PBM’s records show the patient paying $6,000 and capping out his out-of-pocket maximum — when, in fact, the patient has paid nothing — the drug company picked up the tab. “There needs to be collaboration to flag that a co-pay coupon has been used,” Miller stresses.

————————-

Tyrone’s comment: In the interest of full disclosure I know Andrew personally so my comments will not come as a shock to him. My position is that co-pay cards are a good thing for patients and plan sponsors but not so much for non-fiduciary PBMs. 

Here’s a quick story.

A few months back my mom shared with me that she was not on speaking terms with my uncle so I asked why. They often have these disagreements and all is back to normal in a few days. Apparently, she hired my uncle to repair her washer. Something had gone wrong such that it wouldn’t turn. It was an old top loading washer; my mom is frugal like that and won’t spend money on anything new unless it’s the last resort. 

They had agreed on a price of $100 plus parts. Turns out my uncle looked at the back of the machine adjusted some sort of wire and the job was done in 30 seconds!  My mom believed she overpaid and didn’t want to fork over the $100. She is wrong just like Andrew and here’s why.

1) The payer has agreed to its share of the cost so why be concerned with how the patient delivers their end of the bargain hence the washer story. Payers need to be more concerned about the manufacturer revenue PBMs are earning [and not passing back] than the assistance patients are receiving for drugs which don’t qualify for rebates in the first place. This leads me to bullet number two.

2) This is more about the rebate dollars PBMs aren’t getting. Manufacturers offer incentives (rebates, fees, discounts, expenses etc..) in exchange for market share (preferred formulary tier) and when they don’t get market share they don’t pay rebates or not nearly as much. So when a patient is prescribed a non-preferred medication it is likely in lieu of one that is preferred which means the PBM gets zero or less rebate dollars. Instead of paying the money (rebates) to PBMs, manufacturers are reallocating it to patients in the form of lower out-of-pocket costs to boost market share. 

3) Insurers will say they are still paying the same high prices with co-pay cards. The truth is they aren’t paying the same high prices because the tier determines their cost share. Tier 1 might be 80% cost to the insurer while Tier 3 is 50%, for example. If a plan sponsor’s formulary isn’t at least four tiers that is the problem not the co-pay cards. It is true rebates reduce net plan costs. But, so too do lower cost shares. 

4) The less money patients pay out-of-pocket the less likely they’re to be non-adherent which theoretically means reduced physician and hospital costs for the plan sponsor. 

As a fiduciary PBM, I could care less if a manufacturer is willing to fork over $1000, on a patients behalf, for a product we didn’t prefer or left completely off the formulary. We manage our formularies for outcomes and cost-effectiveness not for profit. Any revenue we receive from a manufacturer is passed back 100% to the plan sponsor which ultimately reduces net plan costs.

When two parties enter into an agreement one shouldn’t get upset how the other lives up to their end of the bargain provided it is done ethically and legally. Plan sponsors who don’t like co-pay cards probably agree with my mother’s initial reaction and have been influenced, either directly or indirectly, by non-fiduciary PBMs. My mom eventually paid the $100 now her and my uncle are again on good terms at least for now. 

————————-

THE ROCKY BACKGROUND

As prescription drug prices skyrocket, most notably for specialty medications, some consumers have simply been priced out of certain treatments. In theory, the co-pay card seems the perfect fix, lowering out-of-pocket expenses for commercially insured or cash-paying patients and, in doing so, expanding their treatment options.

“Adherence to doctor’s orders is one of the biggest challenges in the industry,” says Mike Boken, managing partner at BioCentric. And cost is arguably one of the biggest barriers to medication adherence. In fact, 27% of insured patients report a medication’s cost as the main reason for not filling a prescription, according to a Kaiser Family Foundation tracking poll.

It’s difficult to measure just how much cost affects a patient’s ability — or willingness — to follow through with a prescribed medication. According to Boken, cost may be a major influence, but it’s not the only driver affecting adherence rates. “Sometimes adverse events can affect the numbers. Sometimes a patient simply doesn’t like taking a medication,” he says.

Either way, medication cost is an issue for providers, too. Physicians often factor in the depth of a patient’s pockets when prescribing a new medication — and therefore they have been among the biggest and most vocal supporters of co-pay coverage programs. In a CMI/Compas study of promotional preferences, physicians surveyed across nine specialties placed a higher value on patient assistance programs than sample and voucher programs.

Millennial physicians, in particular, are hardwired to think about pricing and often pepper sales reps with questions about coverage and patient costs. “Younger docs grew up with these programs,” Boken says. “They’re still trained to use generics first, but they’re open to co-pay programs.”

But Boken stresses that cost is neither a singular nor an isolated driver. “Newer products usually have some points of differentiation from the generic older products, but the clinical benefit has to be there,” he adds. “Sometimes when we talk about co-pays and payer issues, we lose sight of that.”

Bob Hastings, VP of marketing at co-pay program provider TrialCard, counters that co-pay cards give physicians more flexibility in treatment options. “Physicians are trained to be the experts. We prefer they make a therapeutic choice on behalf of a patient rather than on the formulary’s wishes.”

Read more >>

This document is updated weekly, but why is it important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to health care reform. 

The costs shared below are what the 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.

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.

Note: Prices listed herein are gross thus do not account for rebates, discounts or other purchase incentives which ultimately reduces the net cost.

If you’ve held a 15-minute introductory phone conversation with me then you’re aware of the hidden cash flow tactic referred to as clawbacks.

Our “Medical Waste” investigative series showed how United, the nation’s largest health insurer, and Optum, its pharmacy benefit manager, overcharged some customers for prescription medication. The practice forced many customers to pay a copay that’s higher than the cost of the drug. United then claws back the extra money from the pharmacist. Optum labeled it an “overpayment program.”

“The hand in the cookie jar has been caught,” says Doug Hoey of the National Community Pharmacists Association. “There’s an old saying that sunlight is the best disinfectant. And I think some sunlight has been poured into their situation, and they’re trying to make the best of it. “

United sent us this statement:

“We have reviewed our pharmacy benefits and will update our plans to ensure UnitedHealthcare members pay the lowest price at the pharmacy.”

When we asked if this meant United plans to eliminate the “overpayment program” that forced customers to unknowingly overpay for prescriptions, United responded:

“Once fully insured customers move to the updated benefit plans, our members will pay the lowest price at the pharmacy and the repayment program will no longer be necessary.”

Tyrone’s comment:  Wait, what about self-funded employers? Self-funded employers should be checking to verify these overpayments aren’t occurring within their plans. Higher OOP (out-of-pocket) expenses for patients leads to non-adherence which ultimately means increased hospital or physician costs. 

“They would never say that they are doing something they shouldn’t be doing,” Hoey says. “But the fact that they’re changing their practices… to me, that’s an admission that they were over the line.”

We kept peppering United with questions, asking if the updated plan will increase premiums. In other words, does United plan to cover the losses they’ll see on prescription drugs with an increase in premiums?  They told us details are being worked out.

We asked how the change would impact members, when it would happen and, again, whether members will see a premium increase.  Again, there was no clear answer from United.

“I think they’re realizing that this is wrong, that there’s a huge liability here, whether fraud or illegal,” says insurance fraud investigator Susan Hayes.  “But it’s definitely wrong and I think they realize it.”

Hayes says these changes will only impact some United customers.  You may not realize it, but United offers two types of plans to most businesses: one a fully insured plan, the other a self-funded plan.  Large companies may take part in a self-funded plan in which the employer pays all of the costs, like part of the copays, and United simply manages the program.

In a fully insured plan, usually for smaller- to mid-size businesses, United takes the risk – it pays the copays and charges the employer a fee. According to the United email and Hayes’ interpretation, the change will only take place for fully insured customers – most likely employees of smaller to mid-size companies.

Hayes tells us United may simply raise premiums on these fully insured plans. She says self-funded plans and customers should be asking United questions.

Read More >>

RGA Reinsurance Company, a subsidiary of Reinsurance Group of America, Incorporated, (NYSE: RGA) today released a report identifying 183 high-cost specialty drugs, defined as costing greater than $50,000 annually or $7,000 monthly, based on wholesale acquisition costs (WAC) of each product identified. The report and accompanying management tool serve as a resource to educate and inform healthcare professionals about high-cost drugs.

[Infographic: click to enlarge]

Of the 183 drugs on the list, 126 (69%) cost more than $100,000 per year, and 48 of those (26%) cost more than $200,000 annually. The most expensive drugs in annual cost include:

• Glybera, which is indicated for the treatment of lipoprotein lipase deficiency ($1,210,000). This product is not yet approved by the U.S. Food and Drug Administration (FDA), but is available in Europe.
• Ravicti, indicated for the treatment of urea cycle disorders ($793,632)
• Lumizyme, indicated for the treatment of Pompe’s Disease ($626,400)
• Carbaglu, indicated for hyperammonemia ($585,408)
• Actimmune, for the treatment of severe, malignant osteopetrosis and chronic granulomatous disease ($572,292).

According to the report, hemophilia and related disorders are some of the most expensive diseases to treat medicinally. Treatment options include, 34 different specialty drugs listed at $100,000 or more per year. RGA’s report, which is available to the company’s clients, includes a detailed analysis and disease breakout on hemophilia drug costs.

Read more >>

The health insurance industry has successfully generated a robust national discussion of drug pricing in the U.S.  However, it is not the complete story. Today, most drug companies offer large rebates to pharmacy benefit managers on behalf of different health plans and employers to reduce patients’ out-of-pocket costs. The problem is a significant portion of the savings is not being passed onto the public.

[Click to Enlarge]

Until recently, advocates and policymakers had no idea that health plans extract large price discounts on prescription medicines. This changed rather spectacularly when health insurance giant Anthem Inc. and Express Scripts, the nation’s largest PBM, went to war over how much each company was taking in from drug rebates. In litigation Anthem filed in March with the U.S. District Court for the Southern District of New York, the insurer sued Express Scripts for $15 billion in damages, claiming the PBM, which negotiates prices with drug makers on behalf of insurers and employers, is reaping an “obscene windfall” by not passing along enough of the price breaks to Anthem. Express Scripts then countersued in April, arguing Anthem was the one at fault.

Not surprisingly, when two behemoth corporations sue one another, the battle makes national headlines. However, the Anthem-Express Scripts situation has also produced a valuable side benefit: News of the lawsuits shed light on the extent to which pharmaceutical company rebates can lower the costs to health plans and employers for prescription drugs. According to estimates from ZS Associates, a pharmaceutical marketing consulting firm, drug companies pay about $40 billion annually in rebates with the size of the rebate averaging 30 percent of a medicine’s sales.

Realizing these cost savings may not translate into lower copays or cost-sharing requirements for patients, health plan participants and employers have already sued both companies under the Employee Retirement Income Security Act, a federal law that requires health plans to act in the best interest of beneficiaries. The first suit, filed in May in the same U.S. District Court, was brought by two HIV patients who paid excessive charges to Express Scripts for needed drugs and seek damages for economic harm.

Then in June, three large employers filed a class action suit on behalf of 26,000 insured workers and their family members, stating these individuals paid too much for their drugs because Express Scripts charged “above competitive pricing levels” and Anthem, in effect, allowed these higher prices as part of its contract with the PBM.

What makes these cases especially interesting is the explanation for the Anthem-Express Scripts dispute. As described in the various complaints, in 2009, Anthem entered into a 10-year contract with Express Scripts in which the insurer was offered a choice of less money upfront but lower pricing for prescription drugs or a large upfront payment with higher prices. Anthem chose higher prices over the course of the contract in exchange for $4.6 billion in upfront fees, which the insurer used to buy back stock rather than passing the savings onto plan participants.

Anthem’s complaint alleges Express Scripts raised drug prices for medicines covered by the Anthem plans and overcharged the insurer as much as $3 billion a year. These actions, according to the two class action suits, left plan participants with “significantly higher” percentage-based co-pays.

In light of what has been revealed and the implications for Americans covered by Anthem health plans, should we expect more lawsuits? This is certainly possible given that Express Scripts supports Anthem’s business in over 24 states and services more than 15 million of its members.

Yet, whatever happens, the Anthem-Express Scripts litigation represents a teachable moment for the public.  It is no longer a secret that drug companies pay billions in rebates to PBMs to reduce the price of their medicines. The question is how much of these savings get passed onto insurers, employers, and ultimately consumers. Looking only at the impact on large employers, a recent Pharmacy Benefit

Management Institute survey found about one-quarter of employers received none of the savings from rebates provided to PBMs. A further 30 percent of employers receive flat guaranteed rebate amounts per script. In 2015, these flat guaranteed amounts were $24 per 30-day brand-name prescriptions.

Up until now, there has been almost no scrutiny of the way PBMs manage prescription drug plans for insurers and employers. Clearly now is the time for meaningful change.

STACEY WORTHY   |   AUGUST 12, 2016
Stacey L. Worthy is the executive director of the Alliance for the Adoption of Innovations in Medicine (Aimed Alliance).

This document is updated weekly, but why is it important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to health care reform. 

The costs shared below are what the 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.

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.

Note: Prices listed herein are gross thus do not account for rebates, discounts or other purchase incentives which ultimately reduces the net cost.

In 2010, Fletcher was diagnosed with chronic lymphocytic leukemia. Within 6 months of starting treatment, his disease was in remission. But this good news did not last as he relapsed just 9 months later. He began treatment again, but the results were poor: Fletcher developed congested lungs, a persistent cough, and cataracts that left him temporarily blind. So, his doctor proposed a different treatment. Exhausted, but hopeful, Fletcher was ready to try the new drug until he heard what it would cost him—$2310 out of pocket (OOP) for just one month of treatment. His best chance of survival would consume nearly his entire month’s take-home pay.

It was not long before Jody’s medical bills ate through her family’s savings following her diagnosis with acute lymphoblastic leukemia in 2009. To keep her cancer in remission, Jody is taking a kinase inhibitor that she will likely need for the rest of her life. But when she went to pick up her first dose at the pharmacy, she, too, was shocked to learn how much that lifesaving drug would cost her —$5640 for the first month alone.

Everything that she and her husband had put away for their children’s college educations has gone to keeping Jody alive. Besides leukemia, Fletcher and Jody have something in common: they have had health insurance throughout their cancer treatment journey. Yet, because of the high cost sharing associated with their medications, Fletcher and Jody have faced profound difficulty accessing the treatments prescribed for them.

THE IMPACT OF THE RISING COST OF TREATMENT ON PATIENTS

Figure 1

Over the last decade, employers and other providers of health insurance have shifted more costs onto patients due to a multitude of factors that includes the rising cost of healthcare services. This trend is especially troubling for patients living with a blood cancer diagnosis, since available treatments typically consist of high-priced specialty drugs and other cost-intensive healthcare services. A common discussion with this cost-shifting trend is the steady increase in consumer premium payments, as employee premium contributions have increased 83% since 2006 (compared with a 54% increase for employers over the same period).

Although premium increases have captured the headlines in recent years, the rising OOP costs that patients face, after they pay their premiums, have proven to be even more dramatic (FIGURE 1). In 2003, almost half of patients in employer-provided insurance had no deductible to cover. Ten years later, less than 20% of patients had the same benefit. In fact, as insurers have recognized that increasing deductibles can discourage consumers from accessing their benefits, plans have accelerated this trend. In 2015, the average deductible in an employer-provided insurance plan had increased more than 250% from a decade earlier—increasing 3-times faster than premiums over the same period.

Of specific concern to blood cancer patients are benefit designs that increase the portion of drug costs borne by consumers. This trend is particularly striking in the Medicare Part D marketplace—in 2015, every stand-alone prescription drug plan had adopted a “specialty tier.” Placing a drug in a specialty tier allows the plan to charge patients a percentage of a drug’s list price rather than a fixed dollar amount and simultaneously prevents a patient from accessing Medicare’s cost-sharing appeals process. The impact on affordability is reflected in increases in the number of medications placed on the specialty tier each year.

In the past 4 years alone, Part D plans have shifted 50% more drugs onto their specialty tiers,3 subjecting many patients relying on those medications to thousands of dollars in additional cost sharing. Every day, across the country, blood cancer patients face decisions that pit their health against their family’s finances. And while policy makers, payers, and drug manufacturers engage in debates on drug pricing and a host of related topics— debates that seem far from reaching a productive resolution— patients, like Fletcher and Jody, struggle day to day to access critical medications.

Evidence indicates that once cost sharing exceeds $100, adherence to prescribed medications begins to drop off significantly likely due to the trade-off between paying for medical care and the prospect of damaging the family’s financial stability. Data also show that decreases in adherence correspond to worse outcomes and increases in costly medical interventions that, in many cases, could have been avoided with proper adherence. It is unacceptable and tragic when a patient knows that a potential cure is waiting behind the pharmacy counter but cannot receive it due to his/her inability to pay.

Policy makers ought to give priority consideration to solutions that would meet the following criteria:

• Patients would experience a meaningful improvement in access to care
• Payers could reasonably implement the proposed solution from both a financial and administrative perspective
• The proposed solution will not prohibit a health plan from complying with existing laws and regulations, in particular, actuarial value requirements as established by the ACA

CONCLUSION

To be clear, the cost of medication is just 1 cost that blood cancer patients and their families must face. A proactive and multi-faceted approach to addressing cost and access issues for our communities includes:

1. Working to secure public policies that can reduce the barriers associated with high OOP costs
2. Conducting research into how cost acts as a barrier for treatment access
3. Providing assistance through our copay program to help patients who cannot afford their insurance premiums or drug co-pays
4. Calling on the pharmaceutical and biotechnology industries to share real-world quality of life and outcomes data to support the pricing for their medications.

We are confident that by collaborating with key stakeholders we can dramatically improve patient access to these important therapies.

See more at: http://www.ajmc.com/journals/evidence-based-oncology/2016/august-2016/solutions-for-reducing-patient-cost-sharing-for-medications#sthash.I13GLiu5.dpuf

Global pressure on health spending is forcing the $1 trillion-a-year pharmaceutical industry to look for new ways to price its products: charging based on how much they improve patients’ health, rather than how many pills or vials are sold.

In the United States, both parties are promising fresh action on drug prices whoever wins the White House. In Europe, economies are stalled, squeezing state health budgets. And in China and other Asian markets, governments are getting tougher with suppliers.

Source: AARP Annual Rx Price Trends Report

Pricing drugs based on clinical outcomes is one way to ensure that limited funds bring the most benefits to patients now and pay for the most promising medical advances in future. Some experiments in pricing have already been made. But shifting the overall industry to a new model requires improvements in data collection and a change in thinking, say drug pricing experts.

“Eventually, we are going to get there,” said Kurt Kessler, managing principal at ZS Associates in Zurich, which advises companies on sales and marketing strategies. “But it is a long, tough slog because it’s difficult to get the right data and agree on what the right outcomes are to measure.”

In the past, governments and insurers made room in their budgets for new drugs by switching to cheap generics as patents expired on older drugs. But today generics already account for nearly nine out of every 10 prescriptions in key markets like the United States, and fewer big drugs are going off patent.

That leaves little headroom for pricey new medicines for cancer and other hard-to-treat diseases, even as they come to market in growing numbers. The U.S. Food and Drug Administration has already approved 16 new drugs this year.

Investors got a wake-up call on the issue last Friday when $10 billion was lopped off the market value of Novo Nordisk as the world’s biggest diabetes firm warned of falling U.S. prices.
Pharmacy benefit managers administering U.S. health plans are pushing back hard by excluding some drugs deemed too expensive – including Novo’s – leading to a crunch in areas like diabetes, a disease that now accounts for 12 percent of global healthcare spending.

The Danish group has an unusually high exposure to the U.S. market, but it is not alone in signalling tough times ahead. The chief executives of Novartis, Eli Lilly and GlaxoSmithKline have all warned recently that pricing will become increasingly challenging across the board.

Accounting for 40 percent of global drug sales, the fate of the U.S. market is front and centre in the minds of drug company executives, some of whom privately admit to preparing for a “confrontational” period in relations with politicians.

Read more: Future of Drug Pricing: Paying for Benefits?

This document is updated weekly, but why is it important?  Healthcare marketers are aggressively pursuing new revenue streams to augment lower reimbursements provided under PPACA. Prescription drugs, particularly specialty, are key drivers in the growth strategies of PBMs, TPAs and MCOs pursuant to health care reform. 

The costs shared below are what the 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.

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.

Note: Prices listed herein are gross thus do not account for rebates, discounts or other purchase incentives which ultimately reduces the net cost.