Pharmacy Podcast Show – The Fiduciary PBM
– See more at: http://www.pharmacytimes.com/blogs/pharmacy-podcast-show/0715/the-fiduciary-pbm#sthash.CtlPg5Ds.dpuf
Step #1: Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month.
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.
— 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.
Well there was a video, but I suspect CVS flexed its muscle and now there isn’t a trace of it. Mail-order pharmacy services too may not deliver the cost savings promised during the sales pitch which won the legacy PBM your business. In fact, this practice of overcharging is a notorious cash cow for so called transparent or pass-through pricing PBMs whom offer prescriptions via mail-order pharmacy. Think about it…their first priority is shareholder return on equity not eliminating overpayments from clients.
No matter what you’re being told – your PBM is not fully transparent unless it provides a fiduciary standard of care. Most pharmacy benefit managers will overcharge its clients at every available opportunity. Unless of course the PBM offers a fiduciary standard of care and commits to it in writing.
Instead of the typical fee-for-service contract obtain a fiduciary contract which guarantees “net” ingredient cost for prescription drugs dispensed as part of your prescription drug plan. Better yet, create your own fiduciary contract and put it out for bid vis-à-vis a reverse auction. See my earlier blog post, “Time to Blow Up Your PBM Strategy” to learn more about reverse auctions.
Employers pay a higher admin fee with fiduciary contracts, but in the end total costs are significantly reduced. Furthermore, the price paid is completely transparent; there are no [legal] hidden fees. Of course, none of what I’m writing will make much difference if your PBM team is not well-trained or indifferent to change.
Step #1: Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month.
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.
Step #1: Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month.
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.
Step #1: Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month.
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.
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.
While the provider retains control with infusion treatments, with oral drugs, the onus lies with the patient. “We’ve done a lot of research at COA on this, and basically, it’s actually tied to cost,” he said. According to Okon, studies have shown that irrespective of cost, 10% of patients don’t fill even the first prescription, which complicates clinical and payer decisions if the treatment fails.
Feinberg turned to the payers in the room, asking each to explain the strategy for medication therapy management, adherence, compliance, and persistence, and how these expensive medications impact the overall payer budget.
The Payer Strategy
Kiss said that payers have found a way out: negotiating price deals with vendors. But these channels may not be accessible to a clinical oncologist, he said. “So you have a drug that’s $1000, which may be the patient’s out-of-pocket cost. They take the prescription to their Walgreens. And you know Walgreens can get the drug in 48 hours and still do it, but [now] instead of being $1000, it may be $1400.” These variables have resulted in an increasing shift of cost burden to the patient, according to Kiss.
Another complication is that patients have the option of receiving these oral oncology drugs by mail order; if they cannot tolerate the side effects of the drug, they might stop taking them in a few days, “Which can result in huge wastage because now they have the rest of the month’s supply in their medicine cabinet.” Both Feinberg and Kiss noted that this problem is not confined to oncology; already, we are seeing a spillover into rheumatology and other therapeutic areas where novel oral therapeutics are being developed.
See more at: http://www.ajmc.com/journals/evidence-based-oncology/2015/The-American-Society-of-Clinical-Oncology-Annual-Meeting-2015/Will-Specialty-Oncology-Products-Follow-the-Sovaldi-Way#sthash.jGnchLVI.dpuf
Step #1: Obtain a price list for generic prescription drugs from your broker, TPA, ASO or PBM every month.
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.