Every Health Care Plan Sponsor Must Have a System in Place to Make Sure Drugs Work [Tip of the Week]

There are three things I believe every health care plan sponsor should have in place (1) system to make sure members are taking the prescribed drugs (2) system to make sure the prescribed drugs work (3) system to make sure the prescribed drug is going to the right patient. As drugs get more expensive and complex so to must the services PBMs offer to keep pace. Watch the short video (1:30) to see what the Pharmacy and PBM Leader at Deloitte Consulting has to say about achieving optimal clinical and cost outcomes with specialty drugs.Click to WatchWhat is the Certified Pharmacy Benefits Specialist (CPBS®) training program designed for?This educational offering includes knowledge that is critical to effective management of the pharmacy benefit. Each class concludes with a knowledge assessment test to help gauge student comprehension. Students are required to pass a comprehensive final exam with a score of 85% or better to qualify for the CPBS designation.Employee Benefits Enhance your candidacy - one out of two hiring managers prefer job applicants with a certification Stay competitive in the workforce and raise your professional value Network with other employee benefits professionalsNo or low out-of-pocket costs; employer may pick up portion of the costs Employer BenefitsCertified employees drive business goals through increased self-motivation and confidenceUphold or gain competitive advantage in the marketplace because of the PBM mastery held by human capital Internal career advancement for certified staff which reduces hiring and onboarding costs Clients have more confidence in the results of certified staffPharmacy Benefit Managers will provide transparency and disclosure to a level demanded by the competitive market and generally rely on the demands of prospective clients for disclosure in negotiating their contracts. The best proponent of transparency is informed and sophisticated purchasers of PBM services. The purchaser needs to understand not only what they want to achieve in their relationship with their PBM but also the competitive market and their ability to drive disclosure of details on services important to them. Achieving optimal outcomes, cost and clinical, will be more effectively done by a trained eye with personal knowledge of the purchaser’s benefit and disclosure goals.

How Pharmacy Benefit Managers Make Money and What To Do About It [Free Webinar]

How many businesses do you know want to cut their revenues in half? That's why traditional pharmacy benefit managers, and their stakeholders, 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 at the presentation as well. Very informative." Nolan Waterfall, Agent/Benefits SpecialistA snapshot of what you will learn during this 30-minute webinar:Hidden cash flows in the PBM IndustryBasic to intermediate level PBM terminologiesSpecialty pharmacy cost-containment strategiesExamples of drugs that you might be covering that are costing youThe #1 metric to measure when evaluating PBM proposalsSee you Tuesday, 03/08/22 at 2 PM ET!Sincerely,TransparentRxTyrone D. Squires, MBA  10845 Griffith Peak Drive, Suite 200  Las Vegas, NV 89135 Office: (866) 499-1940Mobile: (702) 803-4154P.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.   

New Exposé Reveals Pharmacy Benefit Manager Tactics That Hurt Patients, Providers, Employers, and Taxpayers [Weekly Roundup]

 News and notes from around the interweb:PBMs ranked by market share: CVS Caremark is No. 1. Three companies dominate the pharmacy benefit manager market, accounting for 79 percent of all prescription claims in 2020, according to data from Health Industries Research Companies, an independent, non-partisan market research firm. To assess market share, HIRC used self-reported data from twenty-nine pharmacy benefit manager leaders collected in December 2020 and January 2021.Documenting Patient Interventions Is Essential. The most common MRPs or medication-related problems included Beers criteria medications (mostly antidepressants, protein pump inhibitors, gabapentin, and opioids), medication omission, drug-condition interaction, duplicate therapy, medication nonadherence, drug-drug interactions, untreated conditions, dose that were too low, and doses that were too high. MRPs were also equally prevalent among face-to-face versus phone interventions. However, the presence of documentation in the “assessment” section of the comprehensive medication review (CMR) was higher when MTM was conducted via phone (42%) compared to face-to-face (28%).Join the Movement!A shared opportunity: The future of cell and gene therapy. Despite the many challenges of the last two years, the global cell and gene therapy (CGT) market continues to rapidly expand. The investment landscape for regenerative medicine has grown 16% in 3 years, hitting an all-time high in 2021 of $23.1 billion raised. With more funding pouring in each year and over 2,261 ongoing global clinical trials in regenerative medicine, the market is expected to reach $34.31 billion in 2030. With this immense growth potential, the industry is reaching a tipping point heading towards commercialization.Over 800 Prescription Medications Got More Expensive in January 2022. The list prices for 810 prescription drugs increased by an average of 5.1 percent between Dec. 29 and Jan. 31, according to a GoodRx report released Feb. 4. Of the 810 medications that saw price increases in January, 791 were brand drugs, 19 were generics, 199 were specialty drugs and 84 were healthcare practitioner-administered drugs. The 791 brand drugs' prices increased by an average of 4.9 percent, and the 19 generic drugs' prices increased by an average of 12.6 percent. Price hikes in January 2022 were on par with January 2021, which saw 832 price hikes. In January 2022, drug prices rose by an average of 5.1 percent, half a percentage greater than in January 2021. The price hikes came from 155 drugmakers.New Exposé Reveals Pharmacy Benefit Manager Tactics That Hurt Patients, Providers, Employers, and Taxpayers. The report, “Pharmacy Benefit Manager Exposé: How PBMs Adversely Impact Cancer Care While Profiting at the Expense of Patients, Providers, Employers, and Taxpayers,” was commissioned by the Community Oncology Alliance (COA) and written by industry experts at the law firm of Frier Levitt, LLC. It provides a comprehensive exposé and legal analysis of the most pervasive and abusive PBM tactics, highlighting the adverse impact they have on patients, providers, and health care payers (including Medicare, Medicaid, employers, and taxpayers). The goal is for the report to serve as an authoritative reference for policymakers, regulators, employers, and others seeking greater understanding of PBM behavior while also suggesting solutions to reshape the health care…

Reference Pricing: “Gross” Invoice Cost vs. AWP for Popular Generic and Brand Prescription Drugs (Volume 401)

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.How to Determine if Your Company [or Client] is OverpayingStep #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 acquisition costs then determine if a problem exists. When there is more than a 5% price differential for brand drugs or 25% (paid versus actual cost) for generic drugs we consider this a potential problem thus further investigation is warranted.Multiple price differential discoveries mean 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.

PBMs ranked by market share: CVS Caremark is No. 1 [Weekly Roundup]

 News and notes from around the interweb:PBMs ranked by market share: CVS Caremark is No. 1. Three companies dominate the pharmacy benefit manager market, accounting for 79 percent of all prescription claims in 2020, according to data from Health Industries Research Companies, an independent, non-partisan market research firm. To assess market share, HIRC used self-reported data from twenty-nine pharmacy benefit manager leaders collected in December 2020 and January 2021.Documenting Patient Interventions Is Essential. The most common MRPs or medication-related problems included Beers criteria medications (mostly antidepressants, protein pump inhibitors, gabapentin, and opioids), medication omission, drug-condition interaction, duplicate therapy, medication nonadherence, drug-drug interactions, untreated conditions, dose that were too low, and doses that were too high. MRPs were also equally prevalent among face-to-face versus phone interventions. However, the presence of documentation in the “assessment” section of the comprehensive medication review (CMR) was higher when MTM was conducted via phone (42%) compared to face-to-face (28%).Join the Movement!Documents reveal the secrecy of America's drug pricing matrix. Several people who work in the industry, who asked not to be named due to the confidential nature of coalitions, said most employers, regardless of how big they are, have no idea what they're giving up when they enter coalitions. Once employers are locked into the coalition, they can't get a full second opinion on the drug prices they pay, experts said.Over 800 Prescription Medications Got More Expensive in January 2022. The list prices for 810 prescription drugs increased by an average of 5.1 percent between Dec. 29 and Jan. 31, according to a GoodRx report released Feb. 4. Of the 810 medications that saw price increases in January, 791 were brand drugs, 19 were generics, 199 were specialty drugs and 84 were healthcare practitioner-administered drugs. The 791 brand drugs' prices increased by an average of 4.9 percent, and the 19 generic drugs' prices increased by an average of 12.6 percent. Price hikes in January 2022 were on par with January 2021, which saw 832 price hikes. In January 2022, drug prices rose by an average of 5.1 percent, half a percentage greater than in January 2021. The price hikes came from 155 drugmakers.As It Mulls Whether to Grant Cert in ERISA Case on PBM Fiduciary Liability, Supreme Court Seeks Government's Input. In December, the Supreme Court requested that U.S. Solicitor General Elizabeth Prelogar file a brief in John Doe 1 v. Express Scripts Inc., weighing in on whether the Court should hear a case about prescription drug costs. If the Supreme Court adopts the petitioners' position, pharmacy benefit managers (PBMs) could face significant legal exposure under ERISA for decisions that affect prescription drug prices.The Certified Pharmacy Benefits Specialist (CPBS) educational offering includes knowledge that is critical to effective management of the pharmacy and medical drug benefit. If you want to learn more, click here.

Reference Pricing: “Gross” Invoice Cost vs. AWP for Popular Generic and Brand Prescription Drugs (Volume 400)

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.How to Determine if Your Company [or Client] is OverpayingStep #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 acquisition costs then determine if a problem exists. When there is more than a 5% price differential for brand drugs or 25% (paid versus actual cost) for generic drugs we consider this a potential problem thus further investigation is warranted.Multiple price differential discoveries mean 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.

4 Little Known Ways to Optimize Drug Spend [Tip of the Week]

Managing drug spend efficiently is no easy task. It requires quite a bit of time, effort, and skill to do it right. Anyone with business training can look at a P&L statement and determine whether a company made a profit. However, understanding the story behind the numbers requires a certain set of skills only a certified public accountant can provide, for example. The same can be said for medical and pharmacy benefit drug costs.Pick anyone from HR, finance or procurement and they will tell you succinctly that prescription drugs are expensive. Ask these same professionals how to reduce costs without increasing employee cost share, restricting access, or trimming benefits and you'll get crickets. You're thinking, that's why we hire brokers and consultants. I'll let the note Michael Critelli, former CEO at Pitney Bowes, sent to me address that point."I am pleased that you wrote the particular essay I downloaded. Many corporate benefits departments do not understand that they are overmatched in negotiating with pharmacy benefit managers, as are the "independent consultants" who routinely advise them. The first step in being wise and insightful is admitting what we do not know, and you have humbled anyone who touches this field."For those interested in improving their company's medical and pharmacy benefit drug cost performance and unafraid of unconventional concepts, here are 4 Little Known Ways to Optimize Drug Spend.1) Dr. Sree Chaguturu, the chief medical officer for CVS Caremark, recently made this bold recommendation, "Combine coverage for all specialty medications—including those currently covered in the medical benefit—under the pharmacy benefit." Regardless of the motivation behind the recommendation, Dr. Chaguturu is correct. There are some distinct advantages beyond the obvious potential for realizing lowest net cost. PBMs use utilization management (UM) programs to encourage the use of generics or preferred products, for example. UM is the unsung hero of an efficiently run pharmacy benefits management program. These programs are extremely limited in medical benefits which leads to Fraud, Waste, and Abuse.2) Put the contract front and center during your next RFP (request for proposal).3) Move beyond simple spreadsheet analysis. When conducting a side-by-side claims analysis it is a disservice to plan sponsors when "best price" is calculated from a claim repricing report. Instead, the data must be viewed holistically. Ask yourself, "if the plan were being managed efficiently, what would the final plan cost for this group have been?" A claims analysis or re-pricing looks primarily at retrospective pricing which is a good starting point but does not come close to telling the whole story. For example, it doesn't usually consider poor product mix or bad utilization from which non-fiduciary PBMs intentionally profit. It's not unusual for a legacy PBM's management fee to be higher than your drug costs at the end of a plan year. This management fee is profit which is hidden in the final plan cost. Any cost analysis which doesn't take into consideration the PBM's management fee falls well short of telling the entire story.4) Get PBM educated. “The illiterate of…

Reference Pricing: “Gross” Invoice Cost vs. AWP for Popular Generic and Brand Prescription Drugs (Volume 399)

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.How to Determine if Your Company [or Client] is OverpayingStep #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 acquisition costs then determine if a problem exists. When there is more than a 5% price differential for brand drugs or 25% (paid versus actual cost) for generic drugs we consider this a potential problem thus further investigation is warranted.Multiple price differential discoveries mean 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.

How Pharmacy Benefit Managers Make Money and What To Do About It [Free Webinar]

How many businesses do you know want to cut their revenues in half? That's why traditional pharmacy benefit managers, and their stakeholders, 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 SpecialistA snapshot of what you will learn during this 30-minute webinar:Hidden cash flows in the PBM IndustryBasic to intermediate level PBM terminologiesSpecialty pharmacy cost-containment strategiesExamples of drugs that you might be covering that are costing youThe #1 metric to measure when evaluating PBM proposalsSee you Tuesday, 02/08/22 at 2 PM ET!Sincerely,TransparentRxTyrone D. Squires, MBA  10845 Griffith Peak Drive, Suite 200  Las Vegas, NV 89135 Office: (866) 499-1940Mobile: (702) 803-4154P.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.   

Billionaire Mark Cuban steps up assault on US prescription drug prices, or is he just another player in the mail-order pharmacy market? [Weekly Roundup]

 News and notes from around the interweb: Billionaire Mark Cuban steps up assault on US prescription drug prices. In an interview with Pharmacy Times, Ron Lanton III, Esq, principal at Lanton Law, said entrepreneur Mark Cuban's new venture into the pharmacy field is very interesting, although it maybe just another player in the mail-order pharmacy market. In the interview, Lanton discussed the company's steep discounts on drugs in a myriad of disease states, as well as the company's pharmacy benefits manager, which is expected to be operational in 2023.Is a 90-Day Supply the Best Option to Improve Medication Adherence? Medication nonadherence results in upwards of 100,000 deaths per year and billions in health care spending annually. Whether it is a newly discovered medication or a tried-and-true remedy of the past, a medication only works when it is taken correctly. Medication adherence is essential for each medication to have its therapeutic effect in every patient. Interventions to improve medication adherence may have a greater impact on individual patients and the population as a whole than any novel treatment or therapy. To address nonadherence and remove the potential barrier of accessibility to medications, 90-day supplies are commonly offered as a solution.Join the Movement!Documents reveal the secrecy of America's drug pricing matrix. Several people who work in the industry, who asked not to be named due to the confidential nature of coalitions, said most employers, regardless of how big they are, have no idea what they're giving up when they enter coalitions. Once employers are locked into the coalition, they can't get a full second opinion on the drug prices they pay, experts said.3 reasons to optimize pharmacy benefits before the next open enrollment. Drug spending in the U.S. ballooned to more than $535 billion in 2020 and was projected to increase by another 4-6% by the end of 2021. Two culprits include faster price increases and higher growth in utilization. With drug costs and pharmacy spend on the rise, reducing the cost of Rx benefits is a top priority for many of your self-funded employer clients. To put it simply, sticking with the status quo is not the best option in 2022. Here are three reasons why.Issues Arise as Health Plans Begin Covering At-Home COVID-19 Tests. While plan sponsors and issuers were adjusting their benefits to cover the cost of COVID-19 at-home tests, the administration moved forward with President Joe Biden's order that the federal government purchase five hundred million at-home rapid COVID-19 testing kits to be sent free of charge to Americans who request them. The administration's action is in addition to its policy of allowing Americans to buy and get reimbursed through private insurance for at-home tests.The Certified Pharmacy Benefits Specialist (CPBS) educational offering includes knowledge that is critical to effective management of the pharmacy and medical drug benefit. If you want to learn more, click here.