Hard Questions About Overpaying On Your Pharmacy Budget

It stands to reason that the rising costs of pharmacy is likely on your mind these days. You’re not alone. So it’s worth asking:

  • Are you paying for drugs that are not supposed to be covered in your plan?
  • Are you paying for drugs that should have had prior authorizations but didn’t?
  • Are you paying for more of a drug than your standard plan allows?

If your answer to any one of these questions is “I’m not sure” then your costs may be too high. If you don’t know the answers to these questions, we may have some good news.

I’ve just posted a new episode of “ExcelsiorTV” where we address this very issue and deliver some good news on how to best mine out this information and cut your costs. I look forward to hearing your feedback.


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Hard Questions About Overpaying On Your Pharmacy Budget

It stands to reason that the rising costs of pharmacy is likely on your mind these days. You’re not alone. So it’s worth asking:

  • Are you paying for drugs that are not supposed to be covered in your plan?
  • Are you paying for drugs that should have had prior authorizations but didn’t?
  • Are you paying for more of a drug than your standard plan allows?

If your answer to any one of these questions is “I’m not sure” then your costs may be too high. If you don’t know the answers to these questions, we may have some good news.

I’ve just posted a new episode of “ExcelsiorTV” where we address this very issue and deliver some good news on how to best mine out this information and cut your costs. I look forward to hearing your feedback.


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Clinical Corner: Harvoni’s FDA Approval

Last week, Gilead’s combination Genotype I Hepatitis C product, now officially named Harvoni, was approved by the FDA[1]. The drug is a combination of Gilead’s Sovaldi with a second antiviral agent, ledipasvir, in a single tablet.  It will cost ~$94,500 per 12-week treatment course, in contrast to Sovaldi’s $84,000 cost per 12-week treatment course. Unlike Sovaldi, however, an 8-week treatment course costing $63,000 will also be possible for certain patients receiving Harvoni.

Why is this drug’s launch so important?

94% of treatment-naïve patients who received Harvoni for 8 weeks, and 96% of treatment-naïve patients for 12 weeks achieved sustained viral response (SVR). This means the virus could not be detected in the patient following the course of treatment [2]. Although some physicians may have been withholding pharmaceutical treatment in anticipation of the approval of Harvoni, it is unlikely that the spike in utilization that will follow Harvoni’s approval will be as material as the spike in utilization that followed Sovaldi’s approval. There is potential for Harvoni to replace Sovaldi as the treatment of choice for these patients [3].   Harvoni launched as the first oral, combination product to be approved for the treatment of Hepatitis C and this category is changing rapidly.

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Clinical Corner: Harvoni’s FDA Approval

Last week, Gilead’s combination Genotype I Hepatitis C product, now officially named Harvoni, was approved by the FDA[1]. The drug is a combination of Gilead’s Sovaldi with a second antiviral agent, ledipasvir, in a single tablet. It will cost ~$94,500 per 12-week treatment course, in contrast to Sovaldi’s $84,000 cost per 12-week treatment course. Unlike Sovaldi, however, an 8-week treatment course costing $63,000 will also be possible for certain patients receiving Harvoni.

Why is this drug’s launch so important?

94% of treatment-naïve patients who received Harvoni for 8 weeks, and 96% of treatment-naïve patients for 12 weeks achieved sustained viral response (SVR). This means the virus could not be detected in the patient following the course of treatment [2]. Although some physicians may have been withholding pharmaceutical treatment in anticipation of the approval of Harvoni, it is unlikely that the spike in utilization that will follow Harvoni’s approval will be as material as the spike in utilization that followed Sovaldi’s approval. There is potential for Harvoni to replace Sovaldi as the treatment of choice for these patients [3]. Harvoni launched as the first oral, combination product to be approved for the treatment of Hepatitis C and this category is changing rapidly.

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Weekly CMS Insights: 10/6/14 – 10/10/14

Contract Year 2014 Part D Formulary Administration Analysis

CMS released a memo providing information about an analysis that will evaluate whether Part D sponsors are appropriately adjudicating Medicare Part D drug claims consistent with Part D requirements and sponsors’ CMS-approved benefits.  The memo also describes the methodology that will be used by CMS to complete the monitoring process for this program.

Note: CMS initiated the CY2014 analysis due to their concerns with results from the 2013 formulary administration analysis.  Unlike 2013 where only select sponsors had to provide claims, for 2014, CMS broadened the scope of eligible plans.  Unless your plan is already identified to undergo a program audit in 2014 or if you participated in BOTH a program audit and Formulary and Benefits Administration validation audit in 2013, expect to receive a request.

Recommended Action: Review the attached memo for details.  Information regarding the types of rejected claims (i.e. non-formulary, prior authorization, step therapy, and quantity limits) as well as the date ranges based on plan size are included within the methodology section.

CMS expects a 48-hour turnaround time on providing the data, so request the data NOW from your PBM and begin review of the claims to identify any potential issues.  June 2014 data will be used.

For questions regarding data extraction, submission, or the secure website, please contact Acumen at FormularyBenefits@AcumenLLC.com.  For questions regarding Formulary Administration Analysis, please contact LeAnn Poole at leann.poole@cms.hhs.gov or Réna McClain at rena.mcclain@cms.hhs.gov.

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Weekly CMS Insights: 10/6/14 – 10/10/14

Contract Year 2014 Part D Formulary Administration Analysis

CMS released a memo providing information about an analysis that will evaluate whether Part D sponsors are appropriately adjudicating Medicare Part D drug claims consistent with Part D requirements and sponsors’ CMS-approved benefits. The memo also describes the methodology that will be used by CMS to complete the monitoring process for this program.

Note: CMS initiated the CY2014 analysis due to their concerns with results from the 2013 formulary administration analysis. Unlike 2013 where only select sponsors had to provide claims, for 2014, CMS broadened the scope of eligible plans. Unless your plan is already identified to undergo a program audit in 2014 or if you participated in BOTH a program audit and Formulary and Benefits Administration validation audit in 2013, expect to receive a request.

Recommended Action: Review the attached memo for details. Information regarding the types of rejected claims (i.e. non-formulary, prior authorization, step therapy, and quantity limits) as well as the date ranges based on plan size are included within the methodology section.

CMS expects a 48-hour turnaround time on providing the data, so request the data NOW from your PBM and begin review of the claims to identify any potential issues. June 2014 data will be used.

For questions regarding data extraction, submission, or the secure website, please contact Acumen at FormularyBenefits@AcumenLLC.com. For questions regarding Formulary Administration Analysis, please contact LeAnn Poole at leann.poole@cms.hhs.gov or Réna McClain at rena.mcclain@cms.hhs.gov.

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Webinar Recording: The Future of Specialty Pharmacy is NOW – Lessons Learned From Sovaldi

Thank you for attending the Excelsior Solutions presentation, “The Future of Specialty Pharmacy is NOW – Lessons Learned from Sovaldi.” 

Bob Kordella, R.Ph., Chief Clinical Officer at Excelsior Solutions presented lessons learned from the launch of the Hepatitis C drug, Solvaldi, and insights on how this drug and others will impact the future of specialty pharmacy. 

Please feel free to share out the presentation replay information and presentation handouts.

You can listen to a replay below:

Webcast Recording

And you can download the presentation handouts here:

Presentation Handouts


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Weekly CMS Insights: 9/29/14 – 10/3/14

2013 Final Part D Payment Reconciliation

CMS released a memo informing sponsors that calculations for the 2013 Final Part D Payment Reconciliation have been completed and reflect PDE records submitted through June 30, 2014.  The reports were made available in reconciliation mailboxes at the CSSC on Tuesday, September 30, 2014.  Please contact CSSC at 877-534-2772 if you are unable to access the reports.  In addition, sponsors will receive the Part D Exclusion from Reconciliation Report, which will identify PDEs that were excluded from the 2013 Part D payment reconciliation.

Recommended Action: Review the attached memo for details.  Please note that if filing for an appeal, you must do so by October 15, 2014.  Requests for appeal should be directed to Cheri Rice, and sent to the Reconciliation Support Contractor, Acumen LLC.  You may also file an electronic appeal by submitting the appeal to Acumen at PartDPaymentSupport@acumenllc.com.  Please direct questions regarding this memo to Acumen.

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Weekly CMS Insights: 9/29/14 – 10/3/14

2013 Final Part D Payment Reconciliation

CMS released a memo informing sponsors that calculations for the 2013 Final Part D Payment Reconciliation have been completed and reflect PDE records submitted through June 30, 2014.  The reports were made available in reconciliation mailboxes at the CSSC on Tuesday, September 30, 2014.  Please contact CSSC at 877-534-2772 if you are unable to access the reports.  In addition, sponsors will receive the Part D Exclusion from Reconciliation Report, which will identify PDEs that were excluded from the 2013 Part D payment reconciliation.

Recommended Action: Review the attached memo for details.  Please note that if filing for an appeal, you must do so by October 15, 2014.  Requests for appeal should be directed to Cheri Rice, and sent to the Reconciliation Support Contractor, Acumen LLC.  You may also file an electronic appeal by submitting the appeal to Acumen at PartDPaymentSupport@acumenllc.com.  Please direct questions regarding this memo to Acumen.

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Webinar Recording: The Future of Specialty Pharmacy is NOW – Lessons Learned from Sovaldi

Thank you for attending the Excelsior Solutions presentation, “The Future of Specialty Pharmacy is NOW – Lessons Learned from Sovaldi.” 

Bob Kordella, R.Ph., Chief Clinical Officer at Excelsior Solutions presented lessons learned from the launch of the Hepatitis C drug, Solvaldi, and insights on how this drug and others will impact the future of specialty pharmacy. 

Please feel free to share out the presentation replay information and presentation handouts.
 
You can listen to a replay by clicking the link below:

Webcast Recording

Please click the link below for the presentation handouts:

Presentation Handouts


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