The Employer's Guide Blog for Overseeing PBMs

The Definition of Oversee: to watch over and direct (an undertaking, a group of workers, etc.) in order to ensure a satisfactory outcome or performance.

Three Ways to Avoid Bankrupting Costs for Medical Spend J Code Drugs

Image result for medical spend j code drugs
Radical transparency in pharmacy benefits management 
starts with training and education. Click here to begin yours.

Well not quite bankrupting costs for companies like Amazon, Berkshire Hathway or JPMorgan Chase, but high enough for each to forgo the status quo and walk a new path together. The challenges associated with specialty drugs requires a whole new playbook, one with collaboration as the organizing principle. Third-party payers must be proactive in working with providers and PBMs, in several areas, to rein in specialty drug spend.

Appropriate sites of care. When it comes to specialty drugs, the driver of total cost is not just in the unit pricing but also in how and where those drugs are administered. Working jointly to steer patients to the most effective sites will boost total effectiveness and help control costs.

Clinical management. Given the rapid evolution of the pharmaceutical market, the question is no longer whether a treatment exists for a condition, but how effective it is. The pace of innovation and approvals puts a premium on keeping up with the incoming waves of new research, driving drug choice and adherence to cost-effective protocols, and engaging with patients so they follow treatment as prescribed.

Cost containment. When it comes to pharmaceutical cost and trend, misaligned incentives can get in the way of optimal solutions. Third party payers and providers must streamline their processes, especially as they pertain to medications, and wring out unnecessary expenditures whenever possible. Reducing costs can involve many levers, including standardizing therapies and negotiating prices accordingly, expanding the use of generics and exploring biosimilar alternatives.

To the naked eye what I’ve shared here might be overlooked, yet I can’t stress enough how important sites of care, clinical management and cost-containment are for plan sponsors. We recently worked on a medical Rx claim case for IL-2 (Interleukin-2) where our cost was $51,300 compared to the billed amount of $549,920 for a potential savings of $498,620!

Tyrone Squires, MBA, CPBS

I am the proud founder and managing director of TransparentRx, a fiduciary-model PBM based in Las Vegas, Nevada. We help health plan sponsors reduce pharmacy spend, by as much as 50%, without cutting benefits or shifting costs to employees.

Leave a Reply