Getting Creative in Combating Rising Specialty Drug Costs

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High cost drugs are the most significant cost driver in healthcare today. Because of their therapeutic value (they cure illness), it is very difficult to manage the cost of these specialty medications. Prior approval, quantity limits and high cost-sharing have proven to be among the most effective utilization mechanisms. A study published in The Journal… [Read More]

Insurers and PBMs Taking Action on Opioid Abuse 

Opioid health risk and medical crisis with a prescription painkiller addiction epidemic concept as a group of people running away from a dangerous falling bridge of pills as a medicine addict problem with 3D illustration elements.

Pharmacy Benefit Mangers (PBMs), which run the drug plans for health insurers, are paid on the volume of drugs they sell and have been criticized for lack of transparency and focus on profits. Likewise, health insurers are generally focused on controlling claims costs and don’t fully consider the effects of their decisions to limit access… [Read More]

Pharmacy Shenanigans

Prescription Drug Cost

In evaluating the cost of a medical benefits program, prescription drug costs and in particular, specialty drugs, stand out as the fastest growing and the most difficult to manage cost. As I review programs with clients, I find myself often pointing out that pharmacy is where all the profits are hidden. This has been no… [Read More]

The Pharmacy Game

The Pharmacy Game

I spend a lot of time thinking about the Pharmacy Benefit Management (PBM) business. The dominant players – Express Scripts, CVS Caremark, and OptumRx – own the vast majority of the business. So, why do I get calls every week from little-known or newer players in the business telling me they can blow the doors… [Read More]

Mandatory Mail Order Rx and the Privacy Dilemma

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We have been hearing a lot about the explosion in the cost of specialty Rx that is leaving insurers, health plans, and governmental payors virtually defenseless against their cost (see Sovaldi). One of the mechanisms being deployed to combat the rising price tag is mandatory specialty Rx oversight.  What this basically does is cede total… [Read More]

Employers Find Solutions to Rx Gamesmanship That Increases Their Costs

Facing the erosion of profits due to high-cost brand name drugs coming off patent, the pharmaceutical industry has found a way to keep the profits rolling in. Pharma would like members who face higher copays and costs for name-brand medications with generic alternatives to stay on the branded drugs. To do so, they spend $3-$6… [Read More]

Express Scripts’ Acquisition of Medco and the Prescription Drug Marketplace

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I am excited to share some of my observations from the annual Express Scripts/Medco Leader’s Conference held last week. Drug Cost Trends Clearly, prescription drug cost trends are flattening. Despite the fact that we are living longer and have a greater incidence of chronic and complex conditions, in 2011, the year over year drug cost increase… [Read More]