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How Does Hospice PBM Work?

Introduction

Hospice PBM is an innovative approach to healthcare that aims to improve end-of-life care for terminally ill patients. Hospice care provides a holistic and compassionate approach to healthcare that addresses not just physical needs but also emotional and spiritual needs. In this article, we'll look at how hospice PBM works and what it entails.

What is Hospice PBM?

Hospice PBM is an abbreviation for hospice pharmacy benefit management. Hospice PBM combines the principles of hospice care with the benefits of a pharmacy benefit management program. The goal of hospice PBM is to provide patients with the right care at the right time and to help them manage the cost of their care.

How Does Hospice PBM Work?

Hospice PBM works by utilizing a team of healthcare professionals who are knowledgeable in hospice care. This team works together to develop a comprehensive plan of care for each patient, taking into account their individual needs, preferences, and medical history.

The hospice team consists of a physician, nurse, social worker, and chaplain, who work together to manage the patient's care. This team also works with the patient's family and other healthcare providers to provide the best possible care.

The hospice PBM program also includes a pharmacy benefit management component. This component helps patients manage the cost of their care by negotiating with pharmacies and insurance companies to get the best possible prices on medications and other treatments.

Benefits of Hospice PBM:

Comprehensive care: Hospice PBM provides a comprehensive approach to care that addresses the physical, emotional, and spiritual needs of patients.

Cost savings: Hospice PBM can help reduce the cost of care by negotiating with pharmacies and insurance companies for the best prices on medications and treatments.

Improved quality of life: Hospice PBM helps improve the quality of life for patients by providing care that is tailored to their individual needs.

Support for families: Hospice PBM provides support and resources to help families care for their loved ones during the end-of-life stage.

Conclusion:

Hospice PBM is an innovative approach to healthcare that combines the principles of hospice care with the benefits of a pharmacy benefit management program. By utilizing a team of healthcare professionals and negotiating with pharmacies and insurance companies, hospice PBM provides patients with comprehensive care that addresses their individual needs and helps manage the cost of their care.

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Who is SpectrumPS PBM for?

PBMs administer prescription drug benefits on behalf of health insurers, Medicare Part D prescription drug plans, major employers, and other payers. By negotiating with drug manufacturers and pharmacies to control drug spending, PBMs have considerable influence behind the scenes in determining total drug costs for insurers, shaping patient access to drugs, and determining how much is spent on drugs to pay pharmacies. PBMs have come under increasing scrutiny for their role in driving up prescription drug costs and spending.

PBMs are hired by health plans, major employers, unions and government agencies to administer prescription drug coverage programs. In the 1960s, they were developed to handle insurance company claims. In the 1970s, PBMs served as financial mediators in the settlement of prescription drug claims. Today, PBMs not only adjudicate claims, but also create and manage networks of pharmacies, determine prescription forms, set copayments, and establish criteria for prior authorizations and selection of pharmacies. patients.

Originally intended to handle claims on behalf of clients under a pre-determined fee structure, they are often referred to as "invisible brokers" because they are hidden between the patient's insurance company, which PBM works for, and the pharmacy, for which the PBM works. PBM reimburses. fill the prescription

SpectrumPS is dedicated exclusively to the hospice industry for a variety of reasons. We view this business as one that requires the help of a committed, global partner who can support your unique prescribing needs and facilitate access to medications for your patients when needed. You will engage more deeply than ever with your patients and ensure that they remain comfortable, cared for and at peace using our pharmaceutical solutions and our network of carefully selected pharmacies who are experts in the hospice industry.

SpectrumPS has worked diligently to establish a network of pharmacies close to its patients. And when it comes to our network, a careful selection process ensures that our exclusive selection of pharmacies live up to the call of duty to serve our customers. When you partner with us, you have instant access to our hospice care specialty pharmacies that can process your requests faster, meet the needs of hospice care patients more effectively, and are located in your community, allowing you to provide better care of their patients. . At the same time, you receive competitive prices and clinical support to ensure the success of your surgery.

SpectrumPS is the best fit for your hospice for a number of reasons, but we'll let you find out once we start working together. In the meantime, we'll tell you what we're doing, why, and how it will help your hospice.

Our mission is to provide each of our customers with the pharmaceutical access they need at the lowest possible cost and with the greatest convenience to shift their focus from the pharmaceutical market to quality patient care. Keep your team up to date with current best practices with logistics and delivery tools, support, and training.

Pharmacists established our pharmacist-only program. We have the experience to drive change in the industry, and we always seek to provide customized solutions that enable our customers to deliver more care than ever before.

How is the price of PBM determined?

On behalf of health insurers, Medicare Part D drug plans, major employers, and other payers, Pharmacy Benefit Managers (PBMs) administer prescription drug benefits. By negotiating with drug manufacturers and pharmacies to reduce drug spending, PBMs significantly affect insurers' selection of overall drug prices, limiting patients' access to prescriptions and regulating how much they can charge patients. pharmacies. In terms of their role in driving up prescription drug costs and expenses, PBMs have come under intense scrutiny.

How Do Pharmacy Benefit Managers Affect the Cost of Prescription Drugs?

PBMs serve as intermediaries in the prescription drug distribution system. Accordingly, they:

Create and manage drug coverage lists or forms on behalf of health insurers. Who determines the drugs used by patients and the reimbursable costs?

Use your buying power to negotiate discounts and rebates with pharmaceutical manufacturers

Spec Trumps offers a comprehensive medication management program through its companies, including integrated pharmacy benefit management, specialty pharmacy solutions and prescription delivery services.

Your clients receive personalized pharmaceutical solutions integrated into medical and pharmaceutical benefit packages tailored to the needs of your community. As a provider of PBM solutions and specialized medication management services, you are able to offer thoughtful and personalized medication management services to the people you serve.

What are PBM Services?

By using SpectrumPS as your pharmacy benefit manager, you can expect the following benefits:

Integrated medication management strategies, including specialty pharmacy

The most advanced technologies, reports and analyzes

A secure online membership portal

Practical Member Outreach and Education Strategies

New clinical therapy

Managing Custom Forms

Prescription home delivery services

Twenty-four hours a day, 365 days a year, certified pharmacy professionals have live customer service.

What sets SpectrumPS Benefits Management Services apart from the competition?

SpectrumPS, an accredited provider of innovative pharmacy benefits management services, is committed to ensuring compliance and quality of the pharmacy benefits program while continuing to innovate in critical areas. We are continually evaluating ways to improve our specialty pharmacy services, Medicare Part D coverage, home delivery program, and account management capabilities for the benefit of our customers.

We believe in providing PBM solutions that include comprehensive and advanced medication management services to increase the value of our members' health coverage, improve treatment quality and reduce costs.

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What is the main difference between Electronic Medical Records and Electronic Health Records in PBM?

Some people use the terms "electronic health record" and "electronic health record" interchangeably. However, at the Office of the National Coordinator of Health Information Technology (ONC), you will find that we use Electronic Health Records (EHRs) almost exclusively.

Although it may seem trivial at first glance, the distinction between the two phrases is quite substantial. The term EMR appeared first, and the first EMRs were truly "medical". They were primarily intended for diagnostic and therapeutic use by professionals.

In contrast, “health” refers to “the state of being healthy in body, mind, and spirit; especially… the absence of physical disease or pain… the general condition of the body. The term “health” encompasses much more than “medical”. And EHRs are far superior to EMRs.

How are they different?

Electronic medical records (EMRs) are the digital equivalent of paper medical records in a doctor's office. Medical and treatment histories of patients in a practice are stored in an EMR. EMRs are superior to paper records. EMRs, for example, allows physicians to:

Track data over time

Easily identify patients who need screening or preventive exams.

Check how your patients are doing on specific factors, like blood pressure measurements and vaccinations.

Monitor and improve the overall quality of care of the practice.

However, the information contained in EMRs does not come easily out of practice. It may be necessary to print and send the patient's file to specialists and other members of the care team. In this regard, electronic medical records are inferior to paper records.

Electronic health records (EHRs) perform all of the functions listed above and more. EHRs focus on the overall health of the patient. Go beyond traditional clinical data collected in the provider office and provide a more comprehensive view of patient care. EHRs are intended to extend beyond the initial healthcare organization that collected and compiled the information.

They are designed to exchange information with other health care providers, such as laboratories and specialists, and therefore contain information from all professionals involved in the treatment of hospitalized patients. According to the National Alliance for Health Information Technology, "EHR data may be developed, maintained, and accessed by licensed physicians and personnel from various health care organizations."

Patient information is transferred to the nearest specialist, hospital, nursing home, state or even across the country.

Analytics said, looking at the differences between log formats. That "the EHR represents the ability to easily transmit medical information between stakeholders and to follow a patient's information through the many treatment modalities that the individual receives."

EHRs are intended to be made available to all parties involved in the treatment of a patient, including the patient. In fact, this is an explicitly stated requirement in the Stage 1 definition of “meaningful use” of EHRs.

And this is the decisive factor. Because information becomes more powerful when it is shared securely. Health care is a team effort supported by the exchange of information.

After all, a significant part of the value of the health care delivery system comes from the effective exchange of information from one party to another and, ultimately, the ability of many parties to engage in interactive communication of information. .

Benefits of EHRs

With fully functional EHRs, all team members have immediate access to the latest information, enabling more coordinated and patient-focused treatment. Use of electronic health records,

Even if the patient is unconscious, care may be modified based on the patient's life-threatening allergy communicated by the attending physician to the emergency department physician.

The ability for a patient to log into their chart and see the trend of their lab results over the past year can encourage them to continue taking their medications and maintain the lifestyle adjustments that have leads to improved numbers.

Last week's lab results are already on file. Therefore, no additional tests are necessary to provide the specialist with the information he needs.

Physician's notes regarding the patient's hospitalization can help inform discharge instructions and follow-up care. Facilitate patient transition between care settings.

Yes, there is a one-word distinction between "electronic medical records" and "electronic medical records". But this term contains a universe of distinction.

The EMR provides digital patient records for a single practice. But the EHR allows physicians to quickly share records with other healthcare professionals, regardless of their geographic location. Keeping the terms "medical" and "health" in mind will help you remember which ones.

In other words, the EMR provides a more limited view of a patient's medical history. While the EHR provides a more comprehensive report on a patient's health.

Consider an EHR similar to an EMR, but with additional tools and capabilities to provide a more comprehensive view of a patient's medical history than the often more limited EMR. The EHR generally offers a more comprehensive view of a patient's medical history than an EMR.

The EMR allows for the entry of patient care information, including test results and prescription medications. This type of software can issue repeat prescriptions, schedule patient appointments, and bill patients.

In addition to facilitating electronic prescribing, EHR software provides communication tools that allow healthcare providers from different organizations to collaborate on patient care. For more information, visit https://www.spectrumpsp.com/.

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How does PBM pricing work?

PBMs administer prescription drug benefits on behalf of health insurers, Medicare Part D drug plans, large employers, and other payers. By negotiating with drugmakers and pharmacies to reduce drug spending, PBMs have a significant behind-the-scenes effect on insurers' selection of total drug costs, restricting patients' access to prescriptions and dictating how much pharmacies The greatest scrutiny has been directed directly at PBMs regarding their share of rising prescription drug costs and expenses.

What impact do PBMs have on the cost of prescription drugs?

PBMs work in the middle of the prescription drug distribution system. Accordingly, they:

Create and manage lists or formularies of covered drugs on behalf of health insurers. Who determines the drugs that patients use and the reimbursable costs.

Use your buying power to negotiate discounts and rebates with pharmaceutical manufacturers

and contract directly with individual pharmacies to compensate beneficiaries for drugs provided.

The federal Centers for Medicare and Medicaid Services found that PBMs' ability to negotiate higher discounts from manufacturers has helped lower prescription prices and stem growth in drug spending over the past three years. However, PBMs can also promote the marketing of more expensive drugs rather than more profitable drugs. Since rebates are usually set as a percentage of the manufacturer's list price, Pharmacy Benefit Managers (PBMs) are reimbursed more for expensive drugs than for those that may offer better value at a lower cost. Therefore, consumers with plans with high deductibles or co-payments based on a drug's list price may incur higher costs.

The very idea of ​​pharmaceutical profits can create fear among corporations. It is unclear why prescription drug costs are rising so rapidly and whether Pharmacy Benefit Managers (PBMs) are successfully managing these expenses and delivering the value they should.

We strive to help business leaders like you better understand what's going on behind the scenes in the pharmacy benefits market. Ultimately, this knowledge can help maximize the value of your benefits plan for your organization and your employees.

Prescription Drug Trends

Americans use drug benefits more often than any other element of health care. According to a new study from Express Scripts, it does.

In 2019, approximately 19 prescriptions were filled per person. And more than three-quarters of those prescriptions were filled for patients with chronic conditions.

We are facing a perfect storm of expensive new treatments, higher rates of chronic disease, frequent use of prescription drugs, and rising brand-name drug prices. In 2018, Americans spent $335 billion on prescription drugs; by 2025, this sum is expected to reach $511.1 billion.

The news is devastating for businesses. The rapidly expanding financial risk associated with prescription drugs is currently the top healthcare concern for self-funded employers. Imagine a self-insured company with 1,000 employees; a few unforeseen $1 million drug claims can put them out of business.

Specialty pharmaceuticals are a major cost driver for prescription drugs.

Increasingly expensive brand names and specialty drugs are critical factors in this rising cost. Specialty drugs are the category of expensive treatments for rare or persistent diseases. Usually biological in origin, they require medical supervision, patient care, and skilled drug management and administration.

Few companies have the resources or the will to develop the expert market knowledge of an experienced PBM. However, it is crucial to know that there are alternatives to the typical PBM strategy, which can be opaque and laden with potentially biased incentives.

Employers should be aware that they can exert considerable influence over the management of their drug benefits. At best, negotiate unlimited visibility into all manufacturer revenues and pricing prescriptions based on actual costs, plus acceptable charges for services.

What does the PBM price differential involve?

In the differential pricing model, Pharmacy Benefit Managers (PBMs) charge the payer more than the pharmacy has reimbursed for a given drug and keep the difference for themselves. How much of this payment goes to pharmacies versus PBM's profits is unknown.

Differential pricing contrasts with the “pass-through model,” with PBMs charging payers the exact amount they reimburse pharmacies plus a fixed administrative cost. The federal government requires Medicaid fee-paying service providers to use the transfer model; however, this requirement does not apply to PBM contracts with Medicaid MCOs or the private sector.

How is differential pricing applied?

Pharmacy benefit managers negotiate the cost of each prescription dispensed by a pharmacy. Based on these contract prices, PBM pays the pharmacy.

Differential pricing is used when a pharmacy benefit management (PBM) uses differential pricing to charge more than it pays the pharmacy, whether the practice discloses it or not. They may adopt this tactic when they know the plan sponsor won't do anything.

This results in the plan sponsor regularly paying outrageous fees without your knowledge.

Requirements for prescription drugs and health care costs

Transparency initiatives are gaining momentum in the healthcare sector to increase competition, reduce expenses and increase accountability. The CAA contains several criteria to promote and support these initiatives, such as requiring plans and issuers to report accurate information to government departments on prescription drugs and other health care expenses.

This data submission should include information on the most commonly prescribed and expensive drugs. It also requires the sharing of prescription drug reimbursement information provided by drug manufacturers to entities licensed to market their drugs.

For more information visit https://www.spectrumpsp.com/

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Why do insurers use PBM?

Pharmacy benefit managers, liaisons between drug companies and health insurers who administer consumers' prescription benefits, are at the center of the discussion about why drug prices in the United States are so high.

PBMs were founded in 1968 to handle claims and negotiate lower costs with pharmaceutical manufacturers. PBMs already manage prescription drug coverage for more than 266 million Americans with health insurance.

The Federal Trade Commission is expected to investigate the PBM industry's refund policies this year.

What do PBMs do?

PBMs manage patient drug benefits for health insurers, large employers, Medicare prescription drug programs, and other health benefit providers.

They negotiate price reductions with pharmaceutical companies and govern how pharmacies are rewarded for dispensing drugs. A formulary is a list of preferred medications in a health plan. They also set the amounts of co-payments for patients.

The Association for Pharmaceutical Care Management, which represents PBMs, reports that they save 40% to 50% on prescription drugs or $962 per person each year.

There are concerns about how much PBMs withhold from rebates negotiated with drugmakers and how much is passed on to consumers, health insurers and employer plans.

According to critics, PBMs may have distorted incentives. Because they get discounts and rebates, they may prefer more expensive drugs on formularies.

According to drug manufacturers, paying discounts and rebates to PBMs leads to higher initial list prices. On the other hand, health insurers argue that manufacturers, not middlemen like PBMs, set high prescription prices.

Independent pharmacies say the structure of the supply chain puts them at a disadvantage, as Pharmacy Benefit Managers (PBMs) refer patients to pharmacies or mail-order companies run by insurers that own the PBMs.

With "differential pricing", PBMs charge the insurer or employer more for the drugs than they reimburse the pharmacy, and keep the difference for themselves. This practice has caught the attention of lawmakers. The Congressional Budget Office estimated that eliminating differential pricing in the Medicaid program for low-income people would generate about $900 million in federal savings.

DIR, or “direct and indirect compensation expense,” is a strategy some analysts say PBMs use to increase their bottom line. PBMs charge after-sales fees to healthcare professionals in the network (oncology practices say they are particularly affected) or pharmacies, often months after a patient's medicine has been dispensed.

The PBM industry argues that it lowers prescription costs by negotiating discounts directly with drug manufacturers for listing excessively high prices. The PCMA says the pharmaceutical industry's use of "coupons, co-pay cards, direct-to-consumer advertising and physician fees" is keeping prescription prices high.

PBMs are responsible for reimbursing pharmacies for dispensing drugs to patients. The pharmacy has no control over the sale of the drug. Although having already incurred storage and distribution expenses. The PBM determines the patient's co-payment and the number of reimbursement pharmacies they will receive for each drug covered by the drug plan.

PBM establishes in advance the cost of each drug covered by the plan, and this is the amount that is reimbursed to pharmacies other than its own. Reimbursement rates are often well below the cost of the drug, forcing pharmacies to fill prescriptions at a loss. No one knows how the cost of each covered prescription is determined because PBMs are unregulated and not required to provide their formulas. This information is a "trade secret" of PBM, leaving pharmacists no choice but to appeal any losses they incur in filling the prescription. Despite New York State rules that set out extremely specific appeal procedures, PBM frequently denies or ignores these challenges.

What is the role of Pharmacy Benefit Managers?

PBMs were created in the 1960s and worked for insurance companies to reduce the cost of pharmaceuticals through claims processing. Today, PBMs are significantly more powerful. Among the top 25 Fortune 500 companies, CVS, Express Scripts and Optum are the three largest PBMs in the country.

PBMs do business with virtually all participants in the pharmaceutical supply chain:

insurers For insurance companies and other insurers, PBMs produce forms. A formulary is a list of medications covered by an insurance plan. PBMs have the power to choose which drugs patients will use and how much they will pay for them.

Pharmacists. PBMs deal with pharmaceutical companies to buy prescription drugs for insurance companies.

Pharmacy. PBMs have agreements with pharmacies for the delivery of drugs. PBMs can determine if the pharmacy you select is part of your insurer's network.

Pharmacy benefit managers subject to regulation?

Of course. There are a variety of activities that could be undertaken to better regulate PBMs and reduce the cost of prescription drugs for patients, such as:

Promote transparency

There would be less room for covert manipulation if PBM's actions were more transparent. For example, on January 2, 2022, New York enacted a new law to increase transparency in prescription drug prices and establish criteria that PBMs must meet.

Restriction of discounts

Most reimbursements should go to insurers or patients by law. As an incentive to negotiate costs with drug manufacturers, they could allow a small portion of discounts to continue.

Enforcement of Antitrust Laws

Antitrust authorities must prevent large PBMs from associating with smaller companies. Agencies should also prohibit PBMs from favoring their pharmacies over competitors.

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Does the hospice provide medication?

When a family member is diagnosed with a terminal illness, financial concerns about end-of-life care can discourage them from seeking needed therapies. Fortunately, patients who meet the qualification requirements have several alternatives to receive the support they and their families need during this difficult time.

Is hospice care a personal expense?

Hospice care is available at little or no cost to people with Medicare, Medicaid, or private insurance. If none of these options are available to a patient, SpectrumPS will work with the patient and family to pay for the hospice drug supply and ensure the patient receives the end-of-life care they need.

How is hospice care funded?

Most patients pay their hospice care costs through one of the following individual payment options:

Medicare - The Medicare hospice benefit covers care for most hospitalized patients. The Medicare hospice benefit is intended to help terminally ill patients receive hospice comfort care.

Medicaid – In most states, hospice care is covered by Medicaid. Medicaid is generally available for low-income people, families, seniors, and people with disabilities. Check the eligibility requirements in your state.

Insurance for Individuals: Although most private insurance companies model their coverage for hospice benefits after Medicare, the range may differ.

What types of services does the hospice offer?

Hospice programs provide a full range of end-of-life care, including:

Caregivers

Our highly trained nurses work with the patient's primary care physician and caregivers to manage pain and symptoms in the patient's home, assisted living facility, or nursing home. Additionally, nurses will respond to concerns and educate and train family caregivers on the proper use of medications, medical equipment, and supplies.

Personal hygiene

Nursing aides regularly visit patients to assist family caregivers or long-term care facility employees with personal care needs, such as bathing and toileting. Assistants inform the interdisciplinary group of changes in the patient's physical, emotional, and social conditions to coordinate care.

Prescription drugs

All medications needed to control pain and symptoms of the patient's terminal illness are provided free of charge to the patient. Your hospice care team will coordinate medication deliveries as needed.

Medical devices

If a patient needs medical equipment such as a walker, wheelchair, oxygen, or a hospital bed. The hospice will offer it for comfort and safety. Your hospice care will coordinate the delivery of medical equipment as needed and remove equipment that the patient no longer needs.

Medical equipment

Suppose a patient requires medical supplies such as alcohol wipes, incontinence pads, catheters, bedpans, or skin and wound care products. The hospice will provide for those that are needed and help arrange for those that are not.

Social work services

The hospice social worker assists the patient and family with their organizational and emotional needs. This may involve referring the family to other financial assistance or psychosocial support programs.

Bereavement counseling

Bereavement counselors are available to offer comfort and support to patients coming to terms with their diagnosis, as well as to their families. Family members can access bereavement counseling and support before and after the death of a loved one.

Therapy

Physiotherapy, occupational therapy, and speech therapy are administered to the patient as deemed medically essential by the hospice medical director and IDG.

Temporary respite care

Caregiving can be a physically and emotionally draining task. To help reduce caregiver burnout, patients may be admitted to a hospice facility for up to five days to provide a caregiver with a break. Both caregivers and patients could benefit from a break in their physical and mental health.

SpectrumPS programs are unique

With the care and support provided by the hospice care team. SpectrumPS offers several unique programs at no additional cost to all of our patients.

Additional concern

When a patient begins to show signs that their final hours are approaching. Our unique care model provides an enhanced level of care to ensure we are there for patients and their families when they need us most. We have consistently exceeded the national average in being present at the bedside at the time of death and helping the family during this terrible time.

Veteran Assistance

SpectrumPS is honored to provide end-of-life care to our country's military veterans. Veterans often face unique obstacles because of their service to our country, even after many years. This category covers anxiety, despair, rage, guilt, and insomnia. SpectrumPS staff and volunteers are specially trained to meet the unique requirements of our veterans.

Additionally, we have designed a Veteran Recognition Program to recognize the service and sacrifice of our Veteran patients through a certificate and good presentation.

One day gift

We strive to provide patients with the resources they need to make the most of every day with their families. Our Gift of a Day program allows patients to have the perfect day doing whatever they love, whether it's a special family meal. performance of your favorite music or a chance to try something new.

Newspapers

SpectrumPS volunteers are ready to help patients collect their memories. And photos in a beautiful hardcover book for your families. Life Journals document the patient's life story for future generations to enjoy.

Hospice benefits include prescription drug coverage.

The Medicare Hospice Benefit should pay for all the prescription drugs you need to control the pain and symptoms associated with your terminal illness.

$5 co-payment is required for outpatient pain and symptom medications.

You are not responsible for any medications you receive while confined to an acute hospital or skilled nursing facility (SNF).

Remember that the hospice benefit does not cover medications that are not directly related to your terminal illness. Your standalone Part D plan or Medicare Advantage plan may cover prescriptions unrelated to your terminal condition. But your plan's coverage rules and cost-sharing requirements will apply.

After your hospice selection, Medicare assumes that medications given to relieve pain, nausea, constipation, and anxiety are related to your terminal condition. And it must be reimbursed by your hospice provider, not your Part D plan. If you don't need these drugs to treat your terminal illness, but need them to treat other conditions, ask your hospice provider to inform your plan that the prescriptions are unrelated to your terminal illness before you fill them. Your Part D plan should cover the drug after you receive this information.

Medical supplies for hospice patients may include (but are not limited to) the following: dressings and other wound care supplies.

briefs, pads, and other incontinence care products

gloves

oxygen tubing and supplemental oxygen sources

Shampoos, soaps, body lotions, and barrier creams are examples of personal care products.

Pads and wedges are used as positioning devices.

They have adequate medical equipment in good working order and the necessary medical supplies to allow patients to receive care at the location of their choice. The SpectrumPS team will provide expert teaching and education on the proper use of all medical equipment and hospice supplies for the patient and their caregivers. Additionally, SpectrumPS-trained staff is available 24 hours a day, seven days a week to provide support and answer questions about using hospice equipment and supplies.

Medicare, Medicaid, and most private insurance companies cover all medical equipment and hospice supplies associated with an inpatient's terminal illness. Our team will coordinate this benefit directly with these groups.

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Is SpectrumPS a PBM?

SpectrumPs offers a comprehensive medication management program through its family of companies, including integrated pharmacy benefit management services, specialty pharmacy solutions, and prescription delivery services.

Your clients receive personalized pharmacy solutions that are integrated with health and pharmacy benefit programs and tailored to the unique needs of your community. You can provide thoughtful, personalized medication management services to the people you serve as a combined provider of PBM solutions and specialty medication management services.

SpectrumPs Pharmacy Benefit Management Services dramatically improve the management of your company's pharmacy program. Our PBM solutions include the following:

Improve operational, financial, and clinical performance

Reduce irrational spending

Assist in the management of cost trends.

Determine medication adherence in your population

SpectrumP's PBM solutions simplify the way your benefits team manages your pharmacy program and are backed by an experienced PBM services team who are available to answer any questions you have along the way.

What are PBM Services?

When you choose SpectrumPs as your pharmacy benefit manager, you can expect to experience the following benefits:

Comprehensive medication management strategies including specialty pharmacy

State-of-the-art technology, reports, and analyses.

A safe and secure online membership portal

Practical Tactics for Member Education and Awareness

New clinical treatments

Managing Custom Forms

Prescription drug delivery services to your doorstep

A live customer support service staffed by professional pharmacy technicians is available 24 hours a day, 365 days a year.

What Sets SpectrumPS Pharmacy Benefits Management Services Apart From the Competition

As a trusted provider of innovative pharmacy benefits management services, SpectrumPs is committed to ensuring compliance and quality of the pharmacy benefits program as it evolves in critical areas. We are constantly evaluating methods to improve our specialty pharmacy services, Medicare Part D coverage, home delivery program, and account management capabilities to help our customers.

We believe in providing PBM solutions encompassing comprehensive advanced medication management services to increase the value of our members' healthcare benefits, improve treatment quality, and control costs.

PBM solutions meet the needs of any population

Spectrum's pharmacy benefit management services can be tailored to meet the unique requirements of a wide range of service providers, including:

Self-funded employers

Third-party administrators

Labor organizations

Behavioral Health Organizations

Consultants and brokers

government programs

State-run Medicaid programs

Health insurance programs

health insurance market

Learn more about the organizations SpectrumPs is happy to support.

Why choose SpectrumPs?

SpectrumPs goes beyond standard pharmacy benefit management as a pharmaceutical care services company. We make smart judgments by connecting billions of data points. We identify trends and develop customized solutions for our plan sponsors. And we are constantly working to simplify the system.

local, personalized, and specific service for hospices

SpectrumPS is entirely focused on the palliative care industry, and for good reason. We view this business as one that requires the support of a committed and comprehensive partner who can meet your particular drug requests and facilitate access to drugs for your patients in times of crisis. Through our pharmacy solutions and network of carefully selected pharmacies intimately familiar with the palliative care industry, you'll engage with your patients on a deeper level than ever before, ensuring they stay comfortable. , cared for and at peace.

OUR TECHNOLOGICAL INNOVATIONS

Today's world revolves around technology and SpectrumPS is no exception. We are constantly optimizing our processes to ensure that your palliative care operation runs as smoothly as possible. With smartphone apps and web portals for ordering, tracking, and budget management, technology has revolutionized the traditional approach to hospice, making expert-level care more accessible.

We offer a wide range of delivery alternatives.

SAME DAY AND OUTSIDE HOURS DELIVERY

At SpectrumPS, we offer a variety of delivery alternatives, including same-day, scheduled, and after-hours delivery, to help a fast-track hospice business meet its delivery requirements. We understand that any delay or interruption in care can do more harm to your patients than good. You'll always have access to the medications you need to protect your patients through our network of specialist palliative care pharmacies and select delivery staff.

SUPPORT TO THE IPU

Information on the most acceptable options is available 24 hours a day, seven days a week.

We provide comprehensive solutions for PIU palliative care needs through our network of palliative care-focused pharmacies. And in addition to traditional PBM services, we offer a variety of resources to help palliative care providers do more for their patients. Whether it's round-the-clock care, personalized services, or faster medication processing speeds, we're always on hand to provide the support you need to run your organization.

Convenience pharmacies: because access is essential

At SpectrumPS, we have worked diligently to build a network of carefully selected pharmacies located near your patients. And when it comes to our network, our carefully chosen pharmacies go through a rigorous vetting process to ensure they can serve our customers. When you join us, you have immediate access to our specialized palliative care pharmacies, which can process your requests faster, meet the needs of palliative care patients more effectively, and are conveniently located in your community, allowing you to better serve their needs. patients. At the same time, you benefit from competitive pricing and clinical support to ensure your operation runs smoothly.

In addition to our full suite of services and solutions, we can work directly with your team to develop a custom solution for your hospice. SpectrumPS ensures that your pharmacy experience is always seamless. As you can see, we are more than a pharmacy benefit manager; we are a committed partner willing to become an extension of your organization and help you streamline and improve your care.

SpectrumPS is here to help

Our entire team at SpectrumPS is dedicated to our customers - we're here to help. From the pharmaceutical experts who founded our company to the customer service personnel, you contact to resolve issues, our services, resources, and knowledge are available to you.

So if you're ready to get started with a PBM that can efficiently and cost-effectively manage your palliative care pharmacy needs, call us today and let's get started.

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Who are PBM's customers?

PBMs are companies that administer prescription drug benefits for health insurers, Medicare Part D drug plans, major employers, and other payers. By negotiating with drug manufacturers and pharmacies to reduce drug spending, PBMs have a significant impact on how insurers determine overall drug costs, how patients obtain drugs, and how pharmacies are compensated. PBMs have received increasing attention in recent years due to their role in increasing prescription drug costs and expenses.

What is the relationship between PBMs and pharmaceutical manufacturers?

PBMs and pharmaceutical manufacturers have a delicate relationship. Numerous financial constraints make the relationship between pharmaceutical companies and PBMs difficult to manage and understand.

PBMs act as mediators between pharmaceutical companies and patients, analyzing the cost of a prescription and implementing programs to help patients obtain medications and use the most effective therapies. These programs include the following:

Programs of Rebates

PBMs interact with pharmaceutical companies to establish how the company will offer discounts on specific drugs: the discounts are paid to the PBM. Under the terms of the contract between PBM and the employer or plan sponsor, PBM may transfer all, part, or none of the reimbursement to the employer or plan sponsor.

Coverage by Formulary

A list of prescription drugs, branded and generic, covered by a specific plan. PBM compiles the list with doctors and clinical specialists to include the most effective and cheapest pills. Given the number of prescriptions processed by a PBM, physicians are more likely to recommend a drug covered by the formulary. A pharmaceutical company wants to ensure that its products are covered and packaged for each patient.

Step therapy programs

Step therapy programs are pre-authorization that applies to generic and brand name medications. The initiative aims to ensure that patients have taken a less expensive and beneficial treatment for a specific disease before switching to a more expensive drug.

Prior Authorization Programs

Prior authorization is a cost-cutting measure that helps ensure that prescription drugs are used appropriately. In addition, prior authorizations aim to prevent the inappropriate prescribing or use of specific drugs.

In addition, PBMs are responsible for implementing several programs critical to improving health outcomes, including reducing waste and improving adherence, managing expensive and highly complex specialty medications, and clinical medication management.

How do PBMs interact with their customers?

When an employer contracts with a PBM to develop and maintain a prescription benefits plan, the connection is typically for three years. During the first discovery phase, both parties work together, and in some circumstances with the assistance of brokers and industry experts, to create your ideal pharmaceutical benefits plan by choosing from various franchises, copays, coinsurance, and clinical programs.

Once the plan is formed, the employer entrusts PBM with the responsibility of effectively administering drug benefits and informing employees of their coverage. PBMs typically include contact centers to help members with inquiries about network pharmacies and varying copayments for different medications. Additionally, most PBMs offer websites or mobile apps that make it easy to access information about eligibility, top-ups, pricing, and coverage rules.

Throughout the contract, PBMs are responsible for four main components:

Claims processing

PBMs are responsible for processing and paying prescription drug claims for Prescription Benefit Plan members.

Reimbursement of Refunds

As noted above, PBMs work with pharmaceutical companies to negotiate reimbursement programs. There are many complicated reimbursement structures, but PBM is generally responsible for managing these reimbursements. Depending on the terms of the contract between PBM and the employer or plan sponsor, the employer may receive all, part, or none of the reimbursement amount.

Clinical training programs

Clinical programs aim to provide the most outstanding clinical results possible to members of prescription drug plans. PBMs continually review data and monitor drug consumption to see if adjustments are needed to achieve the ultimate goal of preserving or improving health benefits and reducing costs.

Prior Authorization, Quantity Limitations, and Step Therapy are clinical programs designed to ensure that the highest quality care is delivered to the patient in the most appropriate setting.

Drug Utilization Review

PBMs play a vital role in ensuring the security of health insurance plans. Drug utilization review is a vital program that assesses a drug's effectiveness, potential risks, and drug interactions. Because they manage their pharmacy networks, they can alert patients and physicians to potential adverse drug interactions.

In addition, the PBM establishes specific criteria that must be met before certain pharmaceutical products can be delivered. Measures may include confirming the diagnosis, determining the presence of a genetic component, ensuring that the appropriate tests are performed, and involving a professional during treatment. All of this is to ensure that a patient follows the correct treatment protocol does not exceed the recommended dose and truly responds to the medication.

Ultimately, employers rely heavily on PBMs to provide them with trends and insights into their plan's performance and opportunities for improvement. Therefore, employers must maintain an open line of communication with their PBMs to ensure that their members receive the best possible treatment at the lowest possible cost.

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Will PBMs go away?

PBMs manage prescription drug benefits for health insurers, Medicare Part D drug plans, major employers, and other payers. Negotiate with drug manufacturers and pharmacies to reduce drug expenses. PBMs have a substantial impact on how insurers determine overall drug costs, how patients obtain drugs, and how pharmacies are compensated. PBMs have received increasing attention in recent years due to their role in increasing prescription drug costs and expenses.

What role do pharmacy benefit managers play in determining our prescription drug spending?

PBM is at the center of the prescription drug distribution chain. This is because they:

develop and maintain lists or formularies of covered pharmaceutical products on behalf of health insurers

that impact the prescriptions patients use and how much they pay out of pocket.

Deal directly with individual pharmacies to reimburse pharmaceutical products delivered to beneficiaries by using your purchasing power to negotiate discounts and rebates from drug manufacturers.

According to the Federal Centers for Medicare and Medicaid Services. The ability of PBMs to negotiate higher discounts from manufacturers has driven down prescription prices and slowed drug spending growth over the past three years. However, PBMs may have an incentive to promote expensive pharmaceuticals rather than more profitable ones. Because PBMs often get discounts based on a percentage of the manufacturer's list price. They are reimbursed more for more expensive pharmaceuticals than for drugs that may offer more value at a lower cost. Therefore, those with a plan with a high deductible or copayments based on list price may face higher out-of-pocket payments.

Americans are divided on several issues, including tariffs, building walls, and how to fix our broken health care system. One area that many seem to agree on is the need to replace antiquated healthcare organizations such as pharmacy benefit managers. This contributes to market inefficiencies and rising drug costs.

Pharmacy benefit managers

Pharmacy benefit managers operate the same way travel agencies did in the past, taking advantage of price inflation. By replacing travel agents with a transactional click model, Amazon and others have opened markets for airlines. Certainly, nothing prevents them from bringing the same efficiency to the pharmaceutical industry.

If you have any doubts that pharmacy benefits managers are following the lead of the travel agent, consider this statistic: About nine in ten drug purchases in the United States are generic drugs, which account for about 15 % of our annual drug expenditure. Buyers can buy them from generic manufacturers for about a third of the price and donate them. They can eliminate discounts on purchases of one in ten brand-name drugs.

While discounts help pharmacy benefit managers. They are not required of the rest of us, including pharmaceutical companies. The debate surrounding rebates stems from the fact that they were previously seen as "kickbacks" paid by drug manufacturers to pharmacy benefit managers to influence formulary positioning. Consider the cost of storage space at grocery stores. However, this is not considered illegal due to the existence of so-called safe harbor provisions that protect participants from criminal prosecution.

Both of these simplifications would cut out unnecessary middlemen and buy drugs versus buying any other device, and customers would know the price. Buyers may even insist on paying only for genuine results and be willing to pay the same price for pharmaceuticals as other rich countries. So, for the first time in history, we would have a free global health care market.

Prescription drug prices

While Pharmacy Benefit Managers (PBMs) have a huge impact on prescription prices in the United States. Its presence is little known outside of the pharmaceutical and insurance industries. PBMs have been criticized in recent years for their role in driving up prescription costs in the United States.

To tackle one of the main drivers of rising drug costs, rebates paid by drugmakers to PBMs, the US Department of Health and Human Services (HHS) announced three final rules on 20 November 2020, revising existing safe harbors and introducing new anti-bribery legislation.

Manufacturers frequently pay rebates to PBMs for preferential placement on the formulary under the current prescription drug reimbursement structure. PBMs have full control over the drug formularies of health insurers who contract with them to administer their administration of prescription drug benefits. Drug formularies are lists of medications that members have access to through their health insurance programs.

Have the poems disappeared?

While the PBM business model is likely to see significant changes in the coming years, PBMs are unlikely to go away.

What's wrong with PBMs?

Although the primary job of a PBM was initially to network and process pharmaceutical claims. These companies have taken advantage of the lack of transparency and established conflicts of interest, dramatically distorting competition, limiting customer choices, and ultimately driving up costs.

Do pharmacists negotiate with PBMs?

Profits accrue to PBMs at virtually every point in the supply chain, from the drug manufacturer to the patient filling the prescription at the pharmacy: PBMs negotiate and retain manufacturer discounts in exchange for prioritizing certain prescriptions in the weather. covered by a particular health plan); they determine…

Why do pharmacies require PBM?

By dealing directly with pharmaceutical manufacturers or wholesalers, PBMs improve patient access to pharmaceuticals. PBMs negotiate volume discounts from wholesale acquisition cost (WAC) to pass on to their customers. Additionally, they negotiate rates based on compliance initiatives.

Does PBMs Help Reduce Drug Costs?

PBMs minimize prescription drug costs by negotiating discounts with drug manufacturers and passing certain savings on to patients and payers, negotiating drug price discounts with retail pharmacies, and dispensing drugs at lower cost through mail-order pharmacies.

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What is a Pharmacy Benefit Manager?

Pharmacy Benefit Managers, or PBMs, have received a lot of attention in recent years. The terms are thrown around whenever the subject of insurance comes up, whether it is health insurance or workers' compensation insurance. If you haven't heard of the term PBM, you've probably heard of specific PBMs, such as Express Scripts or CVS Caremark. And chances are you have a prescription card in your wallet with one of these names on it.

So what is a Pharmacy Benefit Manager? Much of it is in the name: A PBM manages drug benefits under an insurance plan. An insurer, self-insured business, or even the federal government contracts with PBM to manage the pharmaceutical aspects of their insurance plan, from contracting with pharmacies to negotiating discounts and rebates with manufacturers, to processing prescription payments. PBMs, take on the role of managing all aspects of a benefit (prescriptions) on behalf of the insurer and, more specifically, help to control and reduce costs for insurers.

How exactly do they control costs? These negotiated contracts and tariffs mentioned above result in lower costs for the insurer in terms of prescriptions for its policyholders. PBMs negotiate discounts and agreements with drug manufacturers and these negotiations determine whether a certain drug is covered by your drug plan or excluded. These discounts and offers mean that an insurer pays less for a prescription drug than it would without PBM.

Additionally, PBMs often operate pharmacy networks, in which they have a number of pharmacies that they contract with not only to provide patients with access to their medications, but also at a reduced cost to the insurer. They contract with these network pharmacies to fill prescriptions at a reduced rate, and in return, the PBM directs its patients to use these pharmacies. Thus, the pharmacy accepts a lower price for a prescription than it would for someone not covered by this PBM, but in return, it receives a flow of patients.

While PBMs, rebates, and discounts can be confusing, the true function of a PBM is to contain drug costs on a claim. We believe faster healing means lower overall costs. We work closely with physicians, attorneys, and payers to provide the best patient care as a contracted provider in the industry's leading PBM networks.

You can reach us at any time of day or night by contacting us through our 24/7 online customer support chat or by calling  1-8SPECTRUM4 (877.328.7864).

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4 Reasons Why Member Engagement Drives a Health Insurance Plan

Now more than ever, patients want to better understand their healthcare benefits so they can make the best decisions for their health while reducing out-of-pocket expenses.

Plan sponsors play an important role in helping their members navigate their health care benefits. In addition to ensuring great benefits, plan sponsors must use member engagement strategies to help their employees understand their pharmaceutical benefits and therefore get the most out of their plan by making medications more accessible. and affordable for its members.

Truveris identified four reasons why plan sponsors should consider member engagement as an essential part of an effective health insurance strategy.

1. With the rise of consumerism in healthcare, members seek to better understand its benefits

66% of American workers say they want more information from employers about their benefits. Pharmacy benefits in particular are difficult to understand and navigate. Terms like “deductibles,” “step therapy,” and “prior authorizations” can confuse members about their pharmacy journey and what benefits they receive. If members are unable to navigate the pharmacy experience, the risk of overpaying for medications or having delayed care can be extremely high.

To better understand their options, members proactively seek out information on their own. The phrase "how the benefits work" has around 3,000 monthly searches, revealing that many members are struggling to understand their benefits and are looking for help. This highlights an opportunity for plan sponsors to proactively connect their members with the information and tools they need to access their medications. Those who understand how their benefits work is more likely to use them according to their plan, resulting in a healthier, more proactive employee population and cost savings for the organization.

2. Rising drug costs are driving members to seek savings on prescriptions

Health care costs have risen dramatically in recent years, with drug spending accounting for almost 10% of total health care spending. At the same time, as drug prices rise, members incur higher out-of-pocket expenses as they bear more of the cost of their prescriptions. In turn, 50% of patients do not pick up their medications at the pharmacy due to cost, and nearly 73% of consumers would switch pharmacies to save money on their prescription.

To help pay for their medications, members are looking for tools that can help save money. Discount and reimbursement programs offered by drug manufacturers provide members with ways to access their medications at lower prices, making prescriptions more accessible and affordable. Additionally, tools that show members cheaper generics, alternative drugs, and local pharmacies with the lowest price for a drug can help members and plan sponsors save money.

3. Effective member engagement provides data that reveals plan optimizations

Currently, plan sponsors have minimal visibility into their members' benefit usage behaviors. Without insight into claims data trends, plan sponsors have no way to optimize their health benefits plan. Plan sponsors can guide their members to price comparison tools, but many of these solutions don't integrate with the pharmacy plan or guide members through other stages of their journey, such as 'preliminary authorization.

With more advanced technology, employers gain valuable insight into trends such as generic change opportunities, discount card usage, and membership enrollment. Ultimately, this means plan sponsors can better understand how to continually modify the pharmacy benefits program to meet the unique needs of their employees. With a member engagement solution that provides insight into member behavior, plan sponsors can make more informed decisions about future pharmacy benefits contracts and program decisions.

4. Significant benefits can be a differentiator for an organization, especially when paired with member engagement solutions.

In the midst of the "big quiet", it's critical that plan sponsors consider the needs of their employees to attract and retain talent. Notably, nearly 56% of members say employer health care coverage is a key factor in their decision to stay with their current employer. Additionally, nearly half of Americans are interested in tools to help them compare prescription drug prices. To stay competitive in the marketplace and retain valuable employees, plan sponsors must not only provide attractive benefits to their employees but also help plan members feel empowered to make decisions about their unique plan.

Connecting members with coverage tailored to their needs, then providing members with the solution they need to understand how to get the most out of their plan will enable plan sponsors to succeed, increasing employee satisfaction and retention.

Ultimately, members want to be more involved in making informed decisions about their pharmacy journey. To answer this call, plan sponsors should consider implementing a member engagement strategy into their drug benefit program. By connecting members with tools that educate on benefits and present lower-cost drug options, plan sponsors can better influence positive member behavior, save money, and support a healthy and healthy workforce. productive.

You can reach us at any time of day or night by contacting us through our 24/7 online customer support chat or by calling  1-8SPECTRUM4 (877.328.7864).

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Spectrum Pharmacy Solution Hospice and Palliative Care Services

Spectrum Pharmacy Solution (SPS) is a pharmacy benefit manager (PBM) specifically designed for hospices. We have developed several systems that reduce pharmacy costs and improve access. First of all, we have competitive prices thanks to our network contracts. Second, we have developed systems that reduce costs through better drug utilization. Through the notification, clinical education, and therapeutic exchange, the prescribing habits of case managers and physicians can be changed to generate significant cost savings and better treatment outcomes.

Our philosophy is to give you control of your hospice care pharmacy benefit, not take it away from you. Since your staff and physicians are at the bedside, we want to provide them with information so they can make informed decisions. This philosophy has simplified functions and reduced barriers to care.

Some advantages of this program are:

Excellent network prices.

Personalized formulary or list of preferred medications depending on the needs and objectives of the organization.

Reimbursement of participation.

Wide participation of pharmacies.

Personalized mail order programs.

Excellent clinical and financial report (contact us for more information).

Ongoing review of medication use.

Web access for eligibility and pre-authorization.

Support service 24 hours a day, 365 days a year.

Instant eligibility (can interface with current hospice software system)

A pharmacy bill regardless of the number of pharmacies used.

Custom web reports meeting your needs.

Having great pharmacy information and a system to help monitor usage around the clock will improve formulary compliance and reduce costs.

You can reach us at any time of day or night by contacting us through our 24/7 online customer support chat or by calling 1-8SPECTRUM4 (877.328.7864).

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How to Evaluate Your Pharmacy Benefits Management Pricing Agreement

Pharmacy benefits can be difficult for members and employers to understand, even though the cost of prescription drugs consumes a greater portion of medical expenses for both parties. With all the moving parts, it can be increasingly difficult to identify savings opportunities and remember that at the end of the chain is a patient: your employee.

In this article, we'll break down the intricacies of the pharmacy benefits system to expose the opportunities employers and their advisors have to bridge the gaps between cost-effective pharmacy benefits and the patient experience.

Understand the pricing of pharmacy benefits

Despite intentions to offer the best benefits, pharmacy pricing is notoriously tricky, making it difficult for employers and advisors to feel confident in their strategies.

In its simplest form, pharmacy prices are broken down into brand name drug prices versus generic drug prices, and mail order versus retail prices. The price is also affected by the formulary, a list of preferred drugs, and the network of registered pharmacies. Additional elements play a role: co-payment structure, administrative fees, reimbursements, dispensing fees, and clinical program fees.

This complicated pricing formula makes valuation difficult for Pharmacy Benefit Managers (PBMs). It's possible that when employers or consultants question one area of ​​your pricing structure, PBM may simply increase your revenue in another area of ​​the complicated pricing equation. Additionally, PBMs may offer incentives for exclusive mail-order arrangements that have not yet demonstrated savings for the plan.

Recognize weaknesses in pharmacy benefit manager contracts

The pricing formula, however, is just the start. In addition to price discounts and complicated tariffs, employers and their administrators should carefully consider the language of the contract. There are definitions and other terms in typical PBM agreements that could significantly affect overall plan costs. For example, the definition of generic drugs; Plan sponsors often overlook when discounted generics are excluded from coverage in order to increase the overall average discount.

All the moving parts of the pricing formula coupled with cloudy contract language make it very difficult for the plan sponsor to know if they have a good pricing deal with PBM.

Identify hidden PBM practices that affect spend

Unfortunately, there is yet another layer. Earnings received for PBM that are not included in an employer's PBM quote will also affect your pharmacy costs. Mail order is a common example. This has always been a source of income for PBMs, but it is debatable whether mail-order will actually result in substantial savings.

Employers should also pay attention to the formulary (which drugs are covered), as well as who handles the prior authorization process. It is not uncommon for substantial discounts and fees to be paid to PBM to get drugs covered by plans that should be excluded. In many cases, these expensive but low-value drugs can be replaced with one or two generic drugs at a fraction of the cost. In other cases, due to manufacturer requirements, prior authorizations are approved for expensive drugs before cheaper first-line treatments run out.

Follow the next steps

How do we clear up the confusion so that employers can offer a meaningful benefit and employees can get the life-saving drugs they trust? Employers find solutions in pharmacy benefit management arrangements that provide individualized attention to members and fully transparent pricing. This approach ensures employees get the right medication from the right source at the right time. Ultimately, this patient focus and lower net cost provide employers with a sustainable healthcare delivery for the future.

You can reach us at any time of day or night by contacting us through our 24/7 online customer support chat or by calling  1-8SPECTRUM4 (877.328.7864).

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Pharmacy Benefit Management (PBM) Industry

What is the Pharmacy Benefit Management (PBM) Industry?

The term Pharmacy Benefit Management (PBM) industry refers to a group of companies that act as intermediaries between insurance companies, pharmacies, and drug manufacturers. PBMs are responsible for ensuring the reduction of drug costs for insurers and insurance companies. They achieve this by negotiating with pharmacies and drug manufacturers. The discounts are then passed on to the insurance companies. Profits are generated by a small surcharge for drugs or by withholding parts of reimbursements.

Understand the Pharmacy Benefit Management (PBM) industry

Like other sub-sectors of the economy, insurance is a multi-level activity with many players serving a variety of interests and objectives. This means that insurance companies are not the only entities operating in this industry. In fact, this also includes reinsurers, underwriters, and pharmaceutical benefit management companies.

Insurance companies rely on PBMs to manage costs, making them middlemen. PBMs profit from this role by negotiating discounts with drug manufacturers for insurance companies in exchange for introducing the manufacturer's drugs to millions of customers. These companies also negotiate contracts with pharmacies to create networks of retail pharmacies for the distribution of medicines.

PBMs tap into a variety of revenue streams. For example, they charge a service fee for:

Negotiation with pharmacies, insurance companies and drug manufacturers.

Prescription processing

Operation of mail-order pharmacies

Contracts with the biggest insurance companies can quickly change a PBM's outlook, giving them great power when negotiating with drug manufacturers and pharmacies. It's no surprise, then, that competition is fierce, with PBMs scrambling to position themselves optimally for contract negotiations with insurance companies.

Special Considerations

Drug costs have skyrocketed over the years, leading insurance companies to rely heavily on PBMs to control and reduce their liabilities. As such, the industry has seen increased competition among PBMs, as well as consolidation. Mergers and acquisitions (M&A) allow PBMs to grow in size and improve their bargaining power.

In addition to M&A agreements between PBMs, there has also been consolidation between pharmacies and PBMs due to the inherent synergies between the two. Rite Aid purchased EnvisionRX in 2015 and CVS Caremark has long had direct access to the CVS retail pharmacy network.

Criticism of the PBM industry

As the very nature of the business probably implies, PBMs are common targets of lawsuits and government surveillance. As outside resellers, many of their business practices are opaque, so PBMs have not always disclosed rebates, rebates, itemized statements, or percentage savings passed on to insurers.

State legislatures have pushed for more transparency and disclosure provisions to better regulate these companies. In addition, there has been pressure to enforce the fiduciary duty on PBMs, which would require them to act in the best interests of insurers and insurance schemes, similar to the legal duty of financial advisers to act in the best interest of their clients. . All of this serves to indicate possible regulation of the PBM industry that could affect future profitability.

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What is a Pharmacy Benefit Manager (PBM) and how does a PBM impact the Pharmacy Benefit Ecosystem?

Pharmacy benefit managers, also known as PBMs, are essentially the brokers for almost every aspect of the pharmacy benefit market. Many people assume that drug benefits come directly from the health insurance provider when, in fact, PBMs do most of the work for over 80% of employers in the United States.

PBMs are hired by employers, health plans, unions, and other organizations to interact with drug manufacturers and handle prescription-related claims. In short, PBMs are the connectors between employers, members, drug wholesalers, pharmacies,, and pharmaceutical companies, working to facilitate the best possible health outcomes at the best possible cost. Having an effective pharmacy benefits strategy and selecting the right PBM to meet an employer's needs is essential to ensuring the success of a benefits plan, optimizing expenses and protecting employee well-being.

What exactly do PBMs do?

PBMs serve two main purposes: to organize pharmacy prescription drug plan options; and to help patients achieve better health outcomes through increased access to appropriate medications.

To do this, PBMs work with drug manufacturers, wholesalers, pharmacies, and plan sponsors.

Decrease Spending

PBMs negotiate prices with an extensive network of retail or mail-order pharmacies and can offer patients and employers greater access to medications across multiple retail chains at competitive prices.

PBMs offer extensive clinical programs, including quantitative modifications, step therapy, and pre-authorizations, to help benefit plan administrators ensure appropriate medication use, safety precautions, and educational opportunities. savings.

PBMs often serve as advisors to employers by providing advice and recommendations on different plan designs, clinical programs, etc.

Increase Access to Medication

PBMs increase a patient's access to medicines by dealing directly with drug manufacturers or wholesalers. PBMs exchange wholesale acquisition cost (WAC) discounts for quantity discounts that they can pass on to their customers. They also negotiate payments based on membership programs.

PBMs mitigate rising prescription costs and ensure drugs are delivered efficiently and achieve the best outcomes for patient health and well-being. By establishing an extensive network of retail or mail-order pharmacies, PBMs can provide patients and employers with better access to medicines across multiple retail chains.

It is fair to view the relationship between the PBM, the pharmaceutical manufacturer, and the employer as a bit of a game of arm wrestling. PBM is in the middle, connected between manufacturer and employer, and is pushed both ways, to reach a fair deal for both parties and offer solutions to minimize drug benefit costs on prescription.

How does PBM work with pharmaceutical manufacturers?

The relationship between PBMs and pharmaceutical manufacturers is complicated. Many funding-related challenges make it difficult to navigate and understand the interactions between pharma companies and PBMs.

As intermediaries between pharmaceutical companies and patients, PBMs are responsible for determining the affordability of a drug and setting up programs to help patients access drugs and use the most effective treatments. . These programs include:

Rebate Programs

PBMs negotiate with pharmaceutical companies to determine the level of reimbursement the company will offer for certain drugs; reimbursements are made to PBM. Depending on the contract between PBM and the employer or plan sponsor, PBM will pass on all, part, or none of the reimbursement to the employer or plan sponsor.

Formulary Coverage

A formulary is a list of drugs, both brand name and generic, that are covered by a certain plan. PBMs determine the list with the help of physicians and other clinical experts to include the drugs that will be most effective and affordable. Given the volume of drugs that go through a PBM, when a drug is covered on the formulary it is much more likely to be prescribed by a doctor. Ideally, a pharmaceutical company wants to ensure its drugs are covered to reach the patients who need them.

Step Therapy Programs

Step therapy programs are a type of prior authorization that applies to traditional and specialty medications. The program is designed to ensure that patients have tried at least one cheaper drug that is effective for a specific condition, before moving on to a more expensive drug.

Prior Authorization Programs

Prior authorization is a cost-effective feature that helps ensure the appropriate use of prescription drugs. Prior authorizations aim to prevent the incorrect prescription or incorrect use of certain medications.

PBMs are also responsible for implementing other important programs designed to improve health outcomes, such as: reducing waste and increasing compliance, managing expensive and highly complex specialty medications, and clinical medication management.

How does PBM work with employers?

When an employer contracts with a PBM to design and maintain a drug benefit plan, they typically commit to a three-year relationship. During the initial discovery phase, both parties work together, and in some cases with brokers and industry experts, to create your ideal pharmacy benefit plan by choosing from different deductibles, copays, coinsurance, and programs. clinics.

Once the plan is designed, the employer relies on PBM to properly manage their prescription drug benefits and educate their employees about their coverage. PBMs often offer call centers to provide support to members and can answer questions about network pharmacies or different copays for different medications. Most PBMs also offer websites or apps that provide easy access to information on eligibility, top-ups, prices, and coverage rules.

Throughout the contract, PBMs are responsible for four main elements of the agreement:

Claims Processing

PBMs are responsible for processing and paying prescription drug claims under a drug plan.

Rebate Reimbursement

As noted above, PBMs negotiate reimbursement programs with pharmaceutical companies. There are many complicated models for rebate programs, but basically, the PBM is responsible for managing these rebates. Depending on the contract between PBM and the employer or plan sponsor, all, part, or none of the reimbursement amount goes to the employer.

Clinical programs

Clinical programs are designed to promote the best clinical outcomes for members of a prescription drug plan. PBMs continually review data and monitor drug use to determine what adjustments are needed to achieve the overall goal: to maintain or improve health benefits while reducing costs.

Clinical programs include prior authorization, quantity limits, and step therapy, all of which are instituted to ensure that the highest quality of care is provided to the patient in the most appropriate setting.

Drug Utilization Review

It's not always about the money: PBMs also play an important role in drug plan security. Drug use review is a vital program that requires the examination of a drug to determine its effectiveness, potential harms, potential drug interactions and mitigate other safety issues. Since PBMs oversee their own pharmacy networks, they have access to a patient's prescription history and can alert patients or physicians to potential negative drug interactions that could arise from mixing different prescriptions.

The PBM also establishes specific criteria that must be in place before certain drugs can be administered. Criteria could include: verifying the diagnosis; determining if there is a genetic component involved; ensuring that the correct tests are carried out and engaging a specialist during treatment. This is all an effort to ensure that the patient takes the proper steps for the treatment, not exceeding the amount needed, and actually responds to the medication.

Ultimately, employers rely heavily on PBMs to provide them with trends and insights into their plan's performance and how to make improvements. Employers must maintain an ongoing dialogue with their PBMs to ensure that their members always receive the best possible care at the lowest possible cost.

Spectrum Pharmacy Solutions can help you find the PBM that best suits your organization's needs, for up to 25% less than what you are currently paying. Contact our team today to take the first step towards optimizing your PBM contract.

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Pharmaceutical Supply Chain Basics

The pharmaceutical supply chain is the means by which prescription drugs are manufactured and delivered to patients. But the supply chain network is actually very complex and requires a number of steps to be taken to ensure that medicines are available and accessible to patients.

A wide range of stakeholders are also involved in the pharmaceutical supply chain, including manufacturers, wholesale distributors, and pharmacy benefit managers (PBMs).

In such a complex process, the stakes are high for pharmaceutical companies. Incorrectly dispensed drugs affect both company reputation and customer satisfaction, as well as potential profits. An inefficient supply chain could also disrupt patient healing processes and have negative public health effects, according to a report by the Kaiser Family Foundation.

The pharmaceutical supply chain faces its own set of challenges, including supply chain visibility, counterfeit drugs, cold chain shipping, and rising prescription drug prices, which can significantly increase out-of-pocket costs for patients.

In the following article, SpectrumPS breaks down the fundamentals of the pharmaceutical supply chain to uncover strategies for overcoming the most common challenges and ways to ensure patients have consistent access to their medicines.

The pharmaceutical supply chain is the means by which prescription drugs are manufactured and delivered to patients. But the supply chain network is actually very complex and requires a number of steps to be taken to ensure that medicines are available and accessible to patients.

A wide range of stakeholders are also involved in the pharmaceutical supply chain, including manufacturers, wholesale distributors, and pharmacy benefit managers (PBMs).

In such a complex process, the stakes are high for pharmaceutical companies. Incorrectly dispensed drugs affect both company reputation and customer satisfaction, as well as potential profits. An inefficient supply chain could also disrupt patient healing processes and have negative public health effects, according to a report by the Kaiser Family Foundation.

The pharmaceutical supply chain faces its own set of challenges, including supply chain visibility, counterfeit drugs, cold chain shipping, and rising prescription drug prices, which can significantly increase out-of-pocket costs for patients.

In the following article, SpectrumPS breaks down the fundamentals of the pharmaceutical supply chain to uncover strategies for overcoming the most common challenges and ways to ensure patients have consistent access to their medicines.

How does the pharmaceutical supply chain work?

At the most basic level, there are five steps in the pharmaceutical supply chain to ensure that drug inventory is available for distribution to providers and patients, according to a report by Avalere.

These five steps are:

1. Pharmaceuticals are sourced from manufacturing sites.

2. They are transferred to wholesale distributors

3. Filled at retail, mail order and other types of pharmacies

4. Subject to price negotiations and processed through quality and utilization management screens by pharmacy benefit management companies

5. Distributed by pharmacies; and finally delivered and taken by the patients

There are many variations of this basic pharmaceutical supply chain structure, the researchers note, largely due to the constant evolution of supply chain actors.

The essential players in the pharmaceutical supply chain network enable it to run smoothly and efficiently. These players include manufacturers, wholesale distributors, pharmacies, and PBMs.

A pharmaceutical manufacturer supplies a quantity of its products that is ideally equal to consumer/patient demand for its products. These manufacturers then manage the actual distribution of drugs from facilities to drug wholesalers or directly to retail pharmacy chains, specialty and mail-order pharmacies, hospital chains, and some health plans.

In particular, pharmaceutical manufacturers have the most influence over pharmaceutical prices, by evaluating expected demand, future competition, and projected marketing costs to establish wholesale acquisition cost (WAC), according to Researchers.

Next are wholesale distributors who buy pharmaceutical products from manufacturers and distribute them to a variety of customers, including pharmacies.

Some wholesalers sell to a wide range of potential customers, while others specialize in selling particular products, such as organic products, or selling to particular types of customers.

PBMs are the next key players in the supply chain. Although not a direct link in the physical pharmaceutical supply chain, PBMs have become an integral part of most consumer drug purchases.

PBMs work with third-party payers to manage consumer drug purchases by defining which drugs will be paid for and the amounts the pharmacy will receive. This actor also determines the amount the consumer has to pay when filling the prescription based on the discounts he negotiates with the other actors in the supply chain.

Pharmacies are the last stop before drugs reach the patient and perhaps the most important stop as they serve as the information link between PBMs, drug manufacturers and wholesale distributors.

Pharmacies buy drugs from wholesalers or directly from manufacturers. After purchasing products, pharmacies must maintain a large stock of pharmaceuticals and provide information to consumers on the safe and effective use of prescription drugs.

THE PHARMACEUTICAL SUPPLY CHAIN ​​AND DRUG COSTS

The pharmaceutical supply chain greatly influences drug costs. Consumers face higher out-of-pocket expenses and health insurance plans face higher drug costs.

A report from Pharmaceutical Research and Manufacturers of America (PhRMA) found that the complexity and number of players involved in the drug supply chain could be one of the main reasons why prescription drug costs are driving the one of the newspapers.

According to the report, prescription drugs are highly dependent on various negotiations between wholesalers, pharmacies, pharmacy benefit managers and insurers. The authors noted that reimbursements have increased in recent years, but out-of-pocket costs to patients are skyrocketing.

How much a person pays for a brand name drug will depend on their insurance plan, the list of drugs covered, the amount of their deductible, and the agreement a person's insurance company has negotiated with the drug's maker, according to a Time article. . .

Health plans with high deductibles or coinsurance have become more popular, meaning more patients have higher charges and may not be able to benefit from negotiations since their co-pay is based on the list price. instead of the negotiated cost. the researchers said.

Multiple examples of how the complex supply chain can increase costs for patients were discussed in the study.

One example involves a patient who has been prescribed an HIV medication with a list price of $3,000. Although the patient received a 20% reimbursement, her coinsurance is $612 because it is based on the list price. The patient is then obligated to pay $100 more than they would have paid if coinsurance had been based on the negotiated price.

A study by the National Community Pharmacists Association (NCPA) indicated that high generic drug prices have had a negative effect on nearly everyone involved in the pharmaceutical supply chain.

Consumers face higher copays and prices, and health plans grapple with higher drug costs. Doctors are also seeing the need to prescribe alternative drug therapies, and consumers are sometimes turning away from their medications due to rising prices.

The pharmaceutical supply chain presents risks and challenges for both suppliers and consumers. But in the context of a health-conscious society, managing pharmaceutical supply chains presents complexities because it involves life-saving drugs that are life-saving for patients.

MAIN CHALLENGES IN THE PHARMACEUTICAL SUPPLY CHAIN

Although the pharmaceutical supply chain is showing success, it also faces many challenges.

According to a report by researchers from the Imperial College of Science, Technology, and Medicine.

The global information analysis business referred to various challenges in this process, such as lack of coordination, inventory management, lack of demand information, dependence on human resources, management controls, temperature control and shipment visibility.

For example, the "Forrester Effect" is a business technique for analyzing any disruption in the supply chain and is a vital business step. But the Forrester effect is seen at the main manufacturing site, which presents a challenge because it's the least responsive part of the supply chain, the researchers said.

This makes it difficult for companies to adequately address challenges such as supply shortages, national tenders and disease outbreaks.

Researchers from Northeastern University and MIT's Sloan School of Management have also recently looked for ways to address drug shortages. The research article published in Complexity indicated that a common solution is to keep more inventory to ensure that more products are available to treat patients in the event of a product recall.

The researchers also established some tactics to eliminate the effects of outages, including financial mitigation, operational mitigation, and operational contingencies.

"Mitigation tactics are those where the business takes action before an outage and therefore incurs the cost of action whether or not an outage occurs. Operational tactics, such as inventory management, l 'multiple sourcing and production flexibility, are also studied in the literature on supply chain disruptions,' the researchers said.

More specific challenges reported by the Imperial College of Science, Technology, and Medicine researchers included uncertainty in the new drug pipeline. Specifically, which drugs will succeed in trials and what kind of dosage and treatments will be most favorable.

PWC also released a report this year which noted that to meet the demands of a growing market, the pharmaceutical supply chain must undergo a "radical overhaul".

The sweeping overhaul, researchers say, includes more diverse types of products and therapies with shorter life cycles, new ways to assess, approve and monitor drugs, an increased focus on outcomes, new models of health care and many other changes.

In general, the pharmaceutical supply chain is vital to ensure that patients receive the medicines they need without having to face stress or obstacles along the way. Although the supply chain faces various challenges, companies can take the necessary steps to ensure a smooth process from product manufacturing to delivery to patients.

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Payers, Providers and PBMs: Embrace Data Liquidity to Improve Medication Adherence

To help patients access their prescription medications during office closures due to the pandemic, many health plans have relaxed or eliminated drug regulations such as prior authorization (PA) and refill orders. too early.

Despite this temporary relief, many patients still experienced delays in filling their prescriptions.

Solutions such as real-time prescribing benefits (RTPB), electronic prior authorization (EPA), and smart pharmacy workflows can help reduce the benefits and administrative barriers that contribute to these delays and improve compliance with the delivery of prescription drugs along the way.

RTPB technology enables providers, pharmacies and payers to quickly exchange information about benefits coverage and out-of-pocket expenses. Relevant data can emerge within a single healthcare workflow that delivers accurate data directly from the source and can help more patients access their medications.

When providers used an RTPB solution, patients were 19% more compliant when picking up their medications.

Direct connections to payers and pharmacy benefit managers (PBMs) through EHRs and pharmacy systems can also provide urgent answers at critical times throughout the patient journey. Providers can spend less time researching benefits information and more time having productive, timely conversations with patients, especially those in need of affordable game plans. Data liquidity within health informatics can help reveal patient-specific affordability and access information to inform and elevate those discussions before patients hit the pharmacy counter.

Having this type of information at the time of prescription can also break down silos between providers and pharmacies. In a recent survey of physician satisfaction with health insurance plans, respondents gave pharmacy-provider relationships the lowest satisfaction scores of any planned feature. of them

Additionally, less than one in five providers said they initiated AP requests at the time of prescription, and less than 40% had visibility into alternative options when AP was needed. A robust EPA solution can help members of the care team avoid PA requests. before patients arrive at the pharmacy.

“Anything that minimizes interruptions and streamlines processes would be helpful: fewer phone calls, less wait time, more communication tools, and more accurate and detailed information sent by insurance about refusals,” said an independent retail pharmacist with Pennsylvania investigation. . "A lot of times we get 'uncovered/non-covered drugs', but they don't fill in the alternative covered fields... These simple changes would make a day in the life of a pharmacist so much easier."

Many solutions can implement accurate, real-time data, but health regulations can make it difficult to get the information you need. State-level legislation aims to change that, with several active bills seeking to require commercial PBMs and payers to share information about patient benefits and eligibility with providers.

Health plans that can make this kind of data easily accessible through simple, intuitive interfaces will be the ones that earn the trust of providers and pharmacists.

Whether driven by mandates from the Centers for Medicare & Medicaid Services or calls from payers, providers and PBMs demanding data liquidity across the healthcare ecosystem, data sharing at the point of prescription is the future needed to support the prescription decision.

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