Welcome to Pharmacy Outcomes Specialists

Pharmacy Outcomes Specialists (POS) is the premier consulting firm in the pharmacy benefits industry, offering corporate clients, unions, government agencies and managed care organizations leading edge services.  Founded in 1996, Pharmacy Outcomes Specialists is one of the most experienced consulting firms performing over 600 audits and reviewing over 500 million pharmacy claims.  Projects include large complicated audits of Medicare Part D programs, audits of Pharmacy Benefit Managers (PBMs) for compliance with financial and plan terms and our annual educational conference.  Pharmacy Outcomes Specialists’ consultants and partners are a unique group of pharmacists, pharmacy technicians, accountants, financial analysts, attorneys and government specialists.

COMING SOON - A NEW WEB PAGE....For all of you who have told me that this web page is out of date, we are starting a process of creating a brand new web page starting in April 2012...so stay tuned as we roll out the new web page.

IT'S TIME TO START TALKING ABOUT PHARMACY ISSUES!  Stay tuned for a new web page from Pharmacy Outcomes Specialists with a blog page in 2012 where we will be hosting a forum for discussions like these:

April 5, 2012 - THE ELEPHANT IN THE ROOM ISSUE: I said I wouldn't comment on the merger but I just can't help myself.  When I read the op ed from the New York Times (http://www.nytimes.com/2012/04/05/opinion/costs-benefits-and-your-prescription-plan.html?_r=1&ref=opinion#), I maybe expected something different than the Wall Street Journal..I have a lot of respect for New Yorkers.  But really, you thought "That judgment deserves credence because of the thoroughness of the F.T.C.’s eight-month inquiry." Was time all that it took to make the deal OK?  This merger will do nothing for plan sponsors.  With $230 billion of a $300 billion dollar market tied up with two players (CVS/Caremark and the new Express Scripts), why did it take 8 months to figure out that this is a bad thing?  I agree that this leaves lots of room for the "smaller" PBMs like OptumRx, Envision, MedImpact and SXC to take over the business - PBMs that are transparent and much more willing to work with clients and disclose where plan sponsor money is going.  But who is going to carry out the carnage of switching over to these PBMs? Overburdened benefit managers.  Which means it won't get done. And in the mean time, CVS/Caremark (who already owns a pharmacy chain, did I mention?) and Express Scripts will continue to use strong arm tactics to set drug prices at pharmacy chains and take spread off those transactions, charge more for specialty drugs in their "managed and owned" specialty pharmacies than they are willing to pay retail pharmacies and continue to hide rebates.  Really, New Yorkers, you are supposed to be the savvy, hip ones.  I am disappointed.  But more disappointed that the benefits community did little or nothing to stop the merger. Let's look in the mirror, pull ourselves up by the boot straps and try to clean up the mess the FTC just handed to us.

Issue One: Copay Coupons.  How do we stop them because they are driving up the use of the non-preferred drugs?  Does anyone have any ideas?  What is your PBM doing?  How can you change your plan design to avoid a spike in 3rd tier utilization of high cost brand drugs?   Please call me if you do.  Susan Hayes 847 540 9590 x 102.

Issue Two: A client recently called and provided their CVS/Caremark formulary to us for 2012.  They were shocked to find that CVS/Caremark NOW EXCLUDES drugs from coverage.  When did that become a PBMs choice to exclude drugs under a prescription drug program??? Does this mean they are taking over fiduciary responsibility?  And when the client told them they didn't want drugs excluded, Caremark's response was that the client's rebates would be reduced by 30% even though the client had rebate guarantees in the contract.  When is a contract not a contract?  We do agree that the drugs that are being excluded can easily be replaced by lower cost or similar cost alternatives.  But this just seems like a strong arm tactic.   I guess you could say that Caremark does not start with Care!  Do you have Caremark?  Call us and we can help.

Issue Three:

When I got my groceries this week, the cashier handed me this coupon.  Who pays for this $25 gift card?  Isn't this a way to INCREASE use in the plan?  Why would Express Scripts want to increase drug utilization?  Aren't they a benefit manager?  Oops, I forgot, they have to post profits this quarter and one way is to run Walgreen's out of their network and other independent pharmacies and then make members switch to other pharmacies where they are making greater spread and then pay members to do so with a $25 gift card.  Happy Holidays Plan Sponsors!

Issue Four:

Are you and your PBM doing the right thing with the introduction of Atorvastatin (generic Lipitor)?  Here is what POS recommends:

Place Atorvastatin on the LOWEST tier and copay level and place Lipitor on the SECOND lowest copay level UNTIL the cost for Atorvastatin drops below Lipitor costs minus rebates/incentive payments from Pfizer minus discounts.  When the cost for Atorvastatin is lower (as stated above), move Lipitor to the highest and tier copay level BUT no later than June 1, 2012.  DO NOT BLOCK ATORVASTATIN.  Not only is that counter to state generic dispensing laws, it thwarts plan’s efforts to control costs in general by encouraging generics.  Click here to see our summary analysis.

Issue Five:

Fraud Waste and Abuse:  When was the last time your PBM engaged you in a discussion about Fraud in the pharmacy networks.  Experts estimate that fraud accounts for 3% of spend. Call us if you are interested in your own PBM's ability to monitor its network of pharmacies, including its own mail order pharmacy.

Issue Six:

DO THE AWP PRICING ROLLBACK ISSUES HAVE YOU BAFFLED? DO YOU THINK THAT YOUR PBM IS MAINTAINING RELATIVE ECONOMICS FOR YOUR PLAN WITH THE CHANGES?  DO YOU THINK IT IS RIGHT THAT YOUR PBM CAN UNILATERALLY CHANGE AWP PRICING? Please see our position on the AWP Rollback and what has happened since September 25, 2009 with the pricing guides.  Call us with any questions you may have at 847 540 9590 ext 102. Click here for examples of how the rollback will work and margins that mail order facilities will lose.

And two years later in September 2011, First DataBank will cease to publish AWP information.  What do you think the industry will do to a single provider of AWP information?  Call us if you want to discuss pharmacy price manipulation issues.

What do you need to know about contracting with your PBM?  Read this article to understand key requirements and make your contracts more advantageous for you rather than your PBM.

Do you know what Drug Risk Evaluation of Mitigation Strategies and do your members need to be sent one by your PBM?  Click here for an explanation of these requirements for all health care providers. And click here for some additional clarification and information on this important topic.

Contact Us Today to learn more about AWP pricing rollback, Medispan pricing changes, and First DataBank pricing changes.