RJ Health recently attended the 21st annual PBMI (Pharmacy Benefit Management Institute) drug conference and had the opportunity to present insights on leveraging ReimbursementCodes to control Specialty Drug Spend. We were able to learn from industry experts and thought leaders on diverse topics on best managing the pharmacy benefit. Our own Randy Falkenrath, Customer Advocacy Advisor, presented a Continuing Education (CE) talk “Controlling the Specialty Drug Trend” to an attentive audience. Randy reviewed cost drivers of specialty drugs; Price, Utilization and Drug Mix, all which can be controlled to reduce trend.
One outstanding breakout session was presented by Steve Miller, MD, SVP and Chief Medical Officer at Express Scripts. He spoke of the rising cost of drug prices and how pipeline drugs may drive down costs. One key fact that most managers of the medical benefit know is that despite being only a small amount of total claims, the medical benefit total costs are significantly more than that of the pharmacy benefit. Mr. Miller remarked, according to Express Scripts data, that the medical benefit accounts for 2% of all claims but makes up 40% of total cost. This is 10% more than last reported in Express Scripts’ 2015 report on Specialty Drug trend and it is becoming more pressing to utilize cost drivers to reduce this trend.1
Another highlighted topic for discussion at PBMI were Rebatable NDCs. Some State Medicaid plan may reimburse providers only for physician administered drugs and biologicals whose manufacturers participate in the Centers for Medicare & Medicaid Services (CMS) Drug Rebate Program. Some checking for an active status on the CMS list based on the date of service when the drug was administered. This is requiring more and more PBMs to look for a shortcut to determine rebate status without navigating several systems. RJ Health has recently updated ReimbursementCodes with information indicating which NDCs qualify for Medicaid rebates. Our Rebate Optimization Tool can help you navigate the confusing NDC landscape and simplify the process of toggling between ReimbursementCodes and other systems to check for this elusive NDC rebate status.
This year’s PBMI, like all other years, was a great success. The conference provided insightful information and resources into PBM side of the medical pharmacy world and how to leverage cost drivers and NDC Rebates to reduce specialty drug trend.
If you’d like to learn more about RJ Health’s capabilities in reducing specialty drug trend or NDC Rebate capabilities, please email firstname.lastname@example.org.