1. health and fitness
2. drugs

The Difference is Clear...
(See chart below)
20270056
517 Wisconsin Avenue Racine, WI 53403 Why Choose Us? Top ten reasons Lakeview PBM Solutions should manage your company’s prescription program 1. SAVINGS. You can have a good prescription program and save money. Let us show you how. 2. NO FINE PRINT. Our contract is short and easy‐to‐understand. Other PBM contracts can be hundreds of pages long. With us, you get the details without the fine print. 3. NO SPREAD PRICING. We pay the Pharmacy what we bill the Plan. Most PBMs create a spread price and bill the Plan more than they pay the Pharmacy. And – you will never know it. 4. NO HASSLE – GOOD VALUE. We know that HR professionals want fewer phone calls, less complaints, and more service from their PBM. CEO’s and CFO’s want savings. Employees want value. We will bring you a program that can meet all these needs. 5. INDIVIDUALIZED PLAN. PBM programs can be complex and confusing. We work with you to build a prescription plan that meets your needs. No shortcuts. 6. REBATES. Lakeview PBM Solutions will send 100% of all rebate revenue we receive from pharmaceutical manufacturers to our Plans. We do not keep rebate revenue. 7. MAIL ORDER? With us, mail order is an option, but not a requirement. Recent studies show that members utilize 90 day fills at retail four times more than mail order and the cost is virtually the same. If you decide to use mail order, our facility has a fast turn‐around time. 8. TRANSPARENCY. Billing is completely transparent. There are no missing columns. You can track every prescription claim from fill to invoice – nothing is hidden. 9. KEEP BUSINESS LOCAL. Some of our competitors are located in New Jersey, Rhode Island, and Missouri. We are located in Wisconsin. 10. WE CARE. Lakeview PBM Solutions cares about your business and your employees. We value our partnership and will work hard to exceed your expectations. Questions? Just give us a call or send us an email! 262‐995‐9660 [email protected] WhyChooseUs
Glossary of Related Terms 30‐day prescription supply – the most commonly prescribed amount of prescription drugs are packaged for patients when picking up their supply at a retail pharmacy 90‐day supply – this amount of prescription drugs packaged for patients is mostly available through mail order pharmacies and is usually for chronic health conditions Brand Name Drugs – are costly new drugs developed by drug manufacturers that are patented for specific amount of time, which means there is an exclusive window when they can be sold before generic alternatives can enter the marketplace Co‐pay – is a payment or form of coinsurance as defined by a health plan that must be paid each time a medical service is used by an insured person CVS Caremark – in 2007, this large, publicly‐traded, Fortune 100 company was created that combined one of the nation’s largest PBMs with one of the nation’s largest pharmacy chain drug stores Drug Formulary – this is a list of prescription drugs, brand and generic, that are “preferred” by your health plan that will pay for them as part of the coverage, and the list is largely determined by the PBMs Express Scripts, Inc. – this Fortune 100, publicly‐traded company headquartered in St. Louis, Missouri, was granted FTC‐approval Generic Drugs – are inexpensive replications of brand name prescription drugs that have come off patent for competition in the marketplace Health Plan Sponsor – entity (corporation, labor union, government agency, or non‐profit organization) that establishes and maintains insurance plan that must follow government guidelines for participant coverage of clearly defined benefits Mail Order Pharmacy – are traditionally owned by PBMs, these usually out‐of‐state entities offer prescription drugs and supplies through mail delivery services Maximum Allowable Costs (MAC) – caps reimbursement for commonly dispensed drugs when there are generic products Medco Health Solutions – One of the three largest PBMs, this Fortune 100, publicly‐traded company is headquartered in Franklin Lakes, New Jersey, was granted FTC – approval to merge with Express Scripts on April 2, 2012 Medicare Part D prescription drug plan – is the federal insurance benefit added for Medicare recipients in 2006 to help seniors pay for their prescription drugs GlossaryofPBMterms
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Pharmacy Benefit Manager (PBM) – third party administrators hired by health plan sponsors to manage prescription drug benefits for a pool of employees, members, or beneficiaries of prescription drugs and supplies Pharmacy Reimbursement – payment provided through health plan sponsors to pharmacies to compensate them for the purchase and services provided in the distribution of prescription drugs and supplies Prescription Refill – physicians will recommend, especially in the case of chronic conditions, that when a patient finishes a certain amount of prescribed drugs that they continue with another supply Spread Pricing – is the differential that PBMs pocket after telling health plan sponsors they will pay for the prescription drugs to pharmacies, when in fact they pay the pharmacies a lower amount GlossaryofPBMterms
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517 Wisconsin Avenue Racine, WI 53403 262‐995‐9660 www.lakeviewpbm.com About Us: Lakeview PBM Solutions is a prescription benefits manager focused on transparency. It was founded by Pete Ciaramita, an independent pharmacy owner and pharmacist, to offer transparent and cost effective solutions to employers who want to provide prescription benefits to employees and consumers who want to save on prescription costs. A PBM is the “middleman” between pharmacies and insurance companies. PBMs negotiate drug prices with manufacturers and process prescriptions that pharmacies dispense to health plan enrollees and consumers. Lakeview PBM Solutions specializes in working with employers and organizations to build affordable Prescription Insurance Plans that help employers and employees control costs. Large PBMs are one of the fastest growing income entities in the healthcare industry. Often that growth comes at the expense of their clients via unjustifiably high drug prices. We started this business with a different mindset than our corporate competitors. Lakeview PBM Solutions is focused on its clients and does not have answer to public shareholders. Profit is not our number one concern, customer service is. Our primary mission is to provide a streamlined and transparent process that enables employers to offer affordable prescription drug benefits. Transparency means that we will provide you with the information you need relating to the true cost of prescription medicines so that you can make an informed choice as to the drug benefits that your employees will receive. Lakeview PBM is based in Racine, Wisconsin and can assist clients in all states except Kansas, Washington, Vermont and Utah. We stand ready to tailor prescription drug benefit programs that meet the needs of employers. We will work with you to understand your needs and provide you with the means to cost effectively and optimally manage the prescription drug benefits that are provided to your employees. LAKEVIEW PBM SOLUTIONS FREQUENTLY ASKED QUESTIONS
Who is Lakeview PBM Solutions?
Lakeview PBM Solutions is a prescription benefits manager with the consumer in mind. We do
not answer to shareholders and profit is not our number one concern, customer service is. We
work with employers and communities to fight the rising cost of healthcare and keep the local
economy strong. We specialize in working with employers and organizations to build Prescription
Insurance Plans that create a win-win for employers while controlling the employee’s costs as
well. We believe there is a reason traditional PBMs are the fastest growing income entity in the
healthcare industry. It is at the expense of their clients. We just have a different mindset than our
corporate competitors.
How can I be sure Lakeview PBM Solutions is transparent?
The cost savings proof is at your fingertips with an easy to use computer program called Rx
Sense. Employers can access up to the minute data on prescription drug costs right from their
desktop. Claims are shown in real-time. With Rx Sense, you can run reports for auditing purposes
as well.
Do you allow auditing?
Yes. If you wanted to audit us, you would use whatever method you would choose. We do not
have any guidelines or specifications in our contract regarding audits. However, be aware that
traditional PBMs have worded their contracts to give them ways around audits as a pharmacist
in MI discovered…”I was perusing the MI State Contract. MI State can audit Caremark’s records,
at their own expense, but cannot audit…agreements with vendors, pharmaceutical
manufacturers, or distributors, Participating Pharmacies, or other providers of products or
services to the PBM.”
Is this a way for Lakeview PBM Solutions to gain more customers for Lakeview Pharmacy?
No. Lakeview PBM Solutions clients can choose which pharmacy they prefer to go to. They do
not have to use Lakeview Pharmacy.
Can I use any pharmacy?
Yes, there are 63,000 pharmacies in our network including major chains, regional chains, and
independents. You can find the nearest pharmacy to you on our website using the pharmacy
finder on our website.
1. Go to the website — www.lakeviewpbm.com
2. Click on News in black navigation bar at the top of the page.
3. On the far right side, under Provider Locations, click Pharmacy Finder.
4. In the pop-up window, enter your zip code, radius, and then click Locate.
5. Results will appear below the search fields, scroll down to see complete results.
How is the repricing calculated?
We utilize Medispan, one of the two recognized prescription pricing programs in the country. This
allows us to track every NDC, date-of-service, quantity and establishes the price the client would
have paid had they been working with us. We then compare the actual cost the plan was billed by
their PBM.
LakeviewPBMSolutionsFAQs
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How does Lakeview PBM Solutions do their pricing?
Lakeview PBM Solutions sets pricing using discounts off of Average Wholesale Price (AWP) and
Maximum Allowable Cost (MAC). This is the standard method of pricing, how we manage it
though, is what is different. Traditional PBMs have more than one MAC table, some have up to
50. We only have one MAC table. We pay the pharmacy exactly what we bill the plan sponsor.
How does this compare to traditional PBMs?
Our adjudication engine dynamically reviews each possible price of a prescription. We adjudicate
claims at the lowest price of retail price, contracted rate, Usual & Customary, MAC (Maximum
Allowable Cost), or gross amount due. If the pharmacy has a special price lower than our
contracted rate, we will pick it up and pass it on to the member and plan.
Prescription programs are complex by nature. The real issue with us, the pharmacy receives what
the plan is billed for a prescription. Most of our competitors create a spread in what is billed the
plan and what is paid to the pharmacy and the PBM keeps that spread.
We could actually, and sometimes do, pay pharmacies a greater amount than our competitors
and the plans still save money. It’s the hidden spreads and fees that are out of control. When a
price changes - we will pay the pharmacy the updated price. Most PBMs charge the plan the
updated price immediately and delay any price update to the pharmacy 60 to 90 to 180 days. We
do not believe this is ethical, and do not do business that way.
How does Lakeview PBM Solutions make a profit?
Nearly all PBMs use spread pricing, mail order, and rebate revenue to increase their revenue and
profits. They also charge an administration fee on a per claim basis. The only source of revenue
for Lakeview PBM Solutions is the administration fee. Lakeview does not participate in spread
pricing, we pass on 100% of the rebate revenue received back to the Plan Sponsors and do not
profit from mail order programs.
What about rebates?
We partner with Ventegra to manage the rebate program and use their three formularies as a
base for most of our plans.
Can I still utilize a mail order program?
Yes. We use Drug Source Inc. They are located in Elk Grove, Illinois. Ordering is simple with one
form and your prescription. Turn-around time is one to two weeks, at the most.
What about Specialty Pharmacy?
Yes. We use Axium Healthcare out of Florida.
Do you have a website?
Yes, our site is www.lakeviewpbm.com. As a member on the site, you can find a pharmacy,
determine your copay, view the formulary and details of your plan. There is also a Health and
Wellness site you can access. As a non-member you can view details of our Discount Card and a
program called Health Perks. We will continue updating the website to provide more useful tools
and information for our clients.
What else do you offer?
We also have the capability of installing a program called Rx Sense onto a computer in your
office or your HR office. This program will allow you to see claims in real-time as they are being
processed. You can also access reports at your fingertips. Just another tool that allows you to
LakeviewPBMSolutionsFAQs
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see what your plan is billed and what the pharmacy is paid. Nothing is hidden. This is helpful for
auditing purposes as well.
Custom reports (for an additional fee) are anything that isn’t already in the drop down menu
shown below.
How many years of combined experience do you have?
We have a combined experience in the pharmacy industry of more than 50 years. As registered
pharmacists we have a unique insight into how the rising cost of prescriptions has led to tough
choices for consumers and employers.
LakeviewPBMSolutionsFAQs
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AXIUM SPECIALTY PHARMACY FREQUENTLY ASKED QUESTIONS About Axium




Nationwide, clinical specialty pharmacy
One-stop solution for managing high cost therapies
Accredited by Accreditation Commission for Healthcare (ACHC)
Located in Lake Mary, FL
What is a specialty pharmacy?
A specialty pharmacy is a pharmacy that specializes in medications used to treat chronic diseases and
supplies patients, physicians, health plan and providers with high-cost injectable medications that
normally would not be readily available at the local pharmacy. Axium specializes in handling the
dispensing and storing of injectable medications daily and can more easily provide medication delivery to
the site of choice.
What type of medications can Axium provide?
Axium can provide injectable, oral, and compounded pharmaceutical treatments for the following:
*Crohn’s Disease
*Growth Hormone Deficiency
*Hepatitis
*HIV/AIDS
*Mental Health
*Multiple Sclerosis
*Natural Hormone Therapy
*Oncology
*Psoriasis
*Rheumatoid Arthritis
Who do I contact with questions?
Axium’s Pharmacists and Clinicians are available 24 hours a day, 7 days a week, 365 days a year by
calling toll-free 1-888-315-3395. For assistance after hours, a Pharmacist will be notified by pager and will
promptly return the call.
AxiumSpecialtyPharmacyFAQs
DrugSource Inc. Mail Order Lakeview PBM Solutions does offer mail order if that is what best suits the client. We utilize DrugSource, Inc. to process our mail order prescriptions. The facility is located in Illinois and the turn‐around time is between one and two weeks. As you will see on the attached Profile Form, you can order your prescriptions online or by filling out the form. The form is easy to complete and we, and DrugSource, are always available to answer your questions. Depending on how your plan is set‐up, most often the copays will be the same for mail order as 90 day at retail. 90 day at retail is also an option that may be available to you if your employer so chooses. 3
Refill Information
O Use my address on file
This section is for prescriptions you have filled with DrugSource in previous orders.
O Ship to Alternate Address ________________________________________________
Patient Name
DOB
/
/
Rx#
Med
Patient Name
DOB
/
/
Rx#
Med
Patient Name
DOB
/
/
Rx#
Med
Patient Name
DOB
/
/
Rx#
Med
Patient Name
DOB
/
/
Rx#
Med
Patient Name
DOB
/
/
Rx#
Med
Patient Name
DOB
/
/
Rx#
Med
Patient Name
DOB
/
/
Rx#
Med
Patient Profile Form
Remember: You can log onto www.drugsourceinc.com or call our automated refill line (800) 854-8764 for
easy access to refill your medications
4
Contact Physician/Transfer Information
Medication Name/Rx #
Strength
Quantity
Fill out section below if you would like us to contact your
physician or your previous pharmacy* for prescriptions
Prescription Directions
Fill
Now
Doctor Information
Name
Phone
Fax
Fill
Later
Patient Name
Name
Phone
Fax
Name
Phone
Fax
Name
Phone
Fax
Place Orders by
Mail
5
Payment Information
Check the box to choose the type of payment you would like to use for your order.
Amount of Co-payment $ _____________
Please contact us if you have any questions about how
much you should enclose/what your co-pay is.
($20 returned check service charge will apply)
O Credit/Debit/FSA Card
O Use Credit Card on file
O This is a New Credit Card
O Keep On File O One Time Use
O
O
O
Fax*
Email
We also carry:
Pharmacy Name ____________________ Phone (____)_________
O Electronic Check. Include a voided check or its copy.
O Check/Money Order Enclosed Check# ______
Phone
*Prescriptions may be faxed by physician ONLY
*Note: We will need your previous prescription numbers from your pharmacy to transfer. If there are no refills, we will contact your doctor.
O Please contact Physician
O These are transfers from my previous pharmacy
We care about
the needs of our
customers.
That's why we
offer home
delivery of every
product we sell.
O
O
Exp
Date
FSA Debit Card
CVV Code
Security Code
I certify that all information entered on this form is correct and that the named is eligible for benefits under the Prescription Drug Program. I hereby assign to the provider pharmacy any payment due
pursuant to this transaction and future transactions and authorize payment directly to the provider pharmacy. I also authorize release of all information pertaining to the claim to the plan
administrator, underwriter, and sponsor in accordance with the Health Insurance Portability and Accountability Act (H.I.P.A.A).
Signature X ______________________________________________ Date __________________
Durable Medical
Equipment
Over-theCounter Products
Ostomy
Products
Wound
Care Products
DRUGSOURCE, INC.
PO BOX 1366
Elk Grove Village, IL 60009
(800) 854-8764
Fax (847) 258-1913
www.drugsourceinc.com
VIPPS Accredited by the National Association
of Boards of Pharmacy
Frequently Asked Questions
Patient Profile Form
How do I start filling prescriptions with DrugSource?
Complete this patient profile form and mail it in with your
maintenance prescription(s) written for a 90-day supply
OR
Log onto www.drugsourceinc.com to complete the online
patient profile form. You can either mail in the paper
version of your prescription(s) or fill out a request for us
to fax your physician
(*Note: Some physicians may require you to mail in the written
1
Employee Information
Company Name
Group Number
I.D. Number
Bin Number
First
Middle
Last
Address _________________________________________________________ Phone (_____)______________
Street
Apt #
_________________________________________________________ Daytime (_____)_____________
City
How can I refill my prescriptions?
Complete the Section 3 of this form and mail it in
OR
Log onto www.drugsourceinc.com and click “Refill Order /
Status” (have the DrugSource prescription number and Date of
This is NEW information.
Please update my profile.
Cardholder’s Name (Please Print) ________________________________________________________________
prescription. Please check with your doctor’s office.)
What is the turn-around time for my prescriptions?
Please allow 10 to 14 business days to receive your order.
(This time may vary).
Please fill in all areas with the required information.
State
Zip Code
Shipping Address, if different ____________________________________________________________________
Cardholder’s Date of Birth ____ / ____ / _______ O Male O Female Are you pregnant at this time? O Yes O No
Describe Cardholder’s drug allergies/medical conditions: Check here if none: O
__________________________________________________________________
__________________________________________________________________
List Prescription (RX)/OTC Medications you are currently taking (including RXs DrugSource has not filled):
I authorize DrugSource to
dispense generic medication.
O Yes
O No
I understand that refusal of generics
may impact my co-payment.
Attach additional paper, if necessary.
Birth of the patient handy)
OR
Call 800/854-8764 to speak to our customer service team
or use our automated touch-tone refill line
OR
Fax in your refills to 847/258-1913
Print Name of Physician ordering medications ______________________________________________________
Physician Phone Number (_____)_____________________
O Please send me an email notice when my package is shipped.
Physician Fax (_____)_______________________
O Please correspond with me about orders through this email.
EMAIL ADDRESS ________________________________________________________________________________
What if my prescription is out of refills?
Call our customer service team and we can contact your
physician
OR
Log onto www.drugsourceinc.com. Click Refill Order /
Status. Click on View Medication History and click the
prescription you would like to refill. If the prescription is
expired/needs refills, we will contact your physician.
OR
Mail in another written prescription with the patient’s
name and Date of Birth printed on its back
OR
Have the doctor fax in a prescription to 847/258-1913
(Prescriptions may ONLY be faxed by the physician’s office)
Please Note: Each state has its own laws regarding Class II
Narcotic Prescriptions. Please contact us if you have any
questions.
2
Dependent Information
If you have no eligible dependents, check here -- O
Name ______________________________________________________
O Spouse
O Dependent
Date of Birth ____ / ____ / ______
O Male
O Female
Drug Allergies / Medical Condition ________________________________
Doctor’s Name __________________
List Rxs/OTC Meds Currently Taking: ______________________________________________________________________________
Name ______________________________________________________
O Spouse
O Dependent
Date of Birth ____ / ____ / ______
O Male
O Female
Drug Allergies / Medical Condition ________________________________
Doctor’s Name __________________
List Rxs/OTC Meds Currently Taking: ______________________________________________________________________________
Name ______________________________________________________
O Spouse
O Dependent
Date of Birth ____ / ____ / ______
O Male
O Female
Drug Allergies / Medical Condition ________________________________
Doctor’s Name __________________
List Rxs/OTC Meds Currently Taking: ______________________________________________________________________________
TRADITIONAL V S. TRANSPARENT Pete Ciaramita
Amy Schiveley
262‐995‐9670
[email protected]
[email protected]
www.lakeviewpbmsolutions.com
517 Wisconsin Avenue
Racine, WI 53403
Traditional vs. Transparent, Full-Disclosure PBM
Topic
Traditional PBM
Lakeview PBM Solutions
Administrative Fee
Usually very small in order to
appear nominal while in fact
numerous additional revenue
streams supplement the disclosed
administration fee.
Priced as Cost "Plus" based on
services utilized and volume.
May be priced per transaction
or per member per month.
Data Accessibility
Generally restricted to reports or
extracts of the data to limit
access.
Full release and access of all
the claims data.
Provider Contracts
Built-in "Spread" between what
the plan is charged vs. what the
pharmacy is paid.
No “Spread.” Full disclosure
and pass through of the
pharmacy cost. Claims are
auditable.
MAC (Maximum Allowable
Cost)
Many different MAC tables, some
have up to 50.
Full pass through. Options
include State MAC, or
Customized MAC Management.
One MAC table
Mail Order
Encouraged and often
mandatory. Creates two sources
of revenue for PBM. MAC not
typically applied and undisclosed
rebates are much higher.
Optional and outsourced when
in the best interest of plan
sponsor. The same pricing
logic and parameters for mail
vs. retail network.
Rebates
Some rebate dollars are generally
shared with the plan sponsor now,
but full disclosure of all
"incentives" is difficult to access.
Full disclosure and passedthrough unless otherwise
negotiated by the plan sponsor.
Formulary
Rigid - one size fits all. Take it or
leave it.
Flexible and fully customizable
to meet plan goals.
Patient Level Formulary
Unavailable, or limited if available.
Flexible and customizable with
real-time access for changing.
1 517 Wisconsin Avenue
Racine, WI 53403
Topic
Traditional PBM
DataRx
Price Updates
Delayed updates for providers
while plan sponsor is charged
with the latest price creating an
additional revenue stream for the
PBM.
Updated weekly and single file
is used for plan and provider.
Custom NDCs (Repacks)
Allows processing of repacks and
custom NDCs to increase PBM
profit at mail facilities.
If mail order is determined as
cost effective, exclusion of
"repacks" is recommend.
Compounding
Some PBM's cannot process
online and require paper claims.
Process all claims online,
including compounds.
Additional Fees
Charge pharmacies an additional
fee for certain rejected claims
such as, drug/drug interactions.
This fee can be up to $30.00
None
2 TRADITIONAL PBM FREQUENTLY ASKED QUESTIONS What is a Pharmacy Benefit Manager (PBM)? A PBM is the middleman between the pharmacy and the insurance company. They negotiate prices with manufacturers and process prescriptions that pharmacies dispense to health plan enrollee and consumers. The three largest PBMs are Medco Health Solutions, Express Scripts, and CVS Caremark. In their early days, PBMs were fee driven intermediaries and administrators. What is the problem with Traditional PBMs? Traditional PBMs have misaligned their mission and goals with client needs. Clients are often in the dark about actual costs and benefits and bad customer service has led to the distrust. That and the fact that they have been involved in multiple lawsuits over the years have led to PBMs being labeled as “bad.” What is Spread Pricing? Spread pricing is the “missing column” showing the difference between what the plan is billed and what the pharmacy was paid. Examples are listed below in the table. Spreads have been seen up to $200. Mark‐up isn’t always bad, but consumers should be able to see these details. *
Drug Name & Strength Quantity
Billed Sponsor
Paid Pharmacy
SPREAD Pacerone 20mg Metformin 1000mg Atenolol 100mg HCTZ 12.5mg Furosemide 80mg Prevacid 30mg 30 60 90 30 90 30 $51 $18 $80 $11 $36 $122 $28 $17 $7 $4 $7 $122 $23 $1 $73 $7 $29 $0 Garis, Robert, and Farrukh Syed. "Spread Pricing in the Prescription Benefit." Creighton University
Medical Center. N.p., n.d. Web. 22 Nov 2011.
<http://www.pbdsuite.com/documents/SPREAD_BROCHURE.pdf>.
How has this remained hidden for so long? The lack of transparency in the PBM industry and the complex methods used to overcharge for prescription drugs allows them to hide the real cost from their clients. Typically, PBMs do not give their clients complete, itemized billing statements. This is how they are able to hide the spread. What can I do about it? If you manage an employee benefit plan, ask your broker or PBM representative to provide a detailed explanation of your fee structure. Explore the option of a transparent PBM and compare costs. What is the difference between transparent and traditional PBMs? Traditional PBMs use spread pricing, repackaging, and other means to generate income. They do not show the full paper trail of charges, fees, or refunds. They use what we call the “hidden column,” as explained above. Transparent PBMs are exactly that. You can see what is charged to the plan, what is paid in fees, and what is paid to the pharmacy. You also see exactly what refunds are received and where they are dispersed. We do not use any hidden columns. You can see the entire trail of a claim, from your computer, in real time. TraditionalPBMFAQ’s
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Why are transparent PBMs the better choice? A transparent PBM aligns its goals with its clients. Because transparent PBMs have a full‐accountable business model clients have a higher level of trust and understanding the process. Lakeview PBM Solutions has a three‐page contract – very simple and easy to understand. Traditional PBMs can have contracts with over 100 pages. Why should my company go with a transparent PBM? Transparent PBMs do not mandate mail order prescriptions, are not tied to specific pharmacies, and do not make money from rebates. Transparent PBMs provide customized plans to meet each client’s needs and save them money. Is the process to change PBMs simple? It is a simple process to change PBMs. There is some time involved to customize your plan, but the process is not difficult. If the process is so simple, why doesn’t everyone do it? The simple reason is that health care and prescription benefits can be difficult to understand. The decision makers in this area, the CEO or CFO, do not have a whole lot of time to deal with this. They rely on their HR people who are unsure or unaware, of the financial aspect of PBMs. They have gotten snowballed and taken advantage of by the PBM. They do not want unhappy employees when it comes to changing benefits. Clients often stay with the same PBM because they do not have the information they need to realize there are better options available to them and they do not want unhappy people. TraditionalPBMFAQ’s
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517 Wisconsin Avenue Racine, WI 53403 262‐995‐9660 www.lakeviewpbm.com Traditional PBM Spread Examples These are real‐life examples of how the PBM’s increase the spread on some prescriptions. The “SPREAD” is the hidden column that neither the employer nor the pharmacy sees. With a transparent PBM there is no spread and all fees are completely visible. All of the drugs below are generic, imagine the profit from brands! Drug Name Strength Pharmacy paid Employer paid SPREAD (PBM profit)
Amlodipine Amlodipine Amox/Clav Amphetamine salts ER Anastrozole Azithromycin Baclofen Fentanyl patch Fentanyl patch Gabapentin Gabapentin Gabapentin Lamotrigine Levetiracetam Morphine ER Nifedipine ER Paroxetine Paroxetine Paroxetine Quinapril Quinapril Ranitidine Ropinirole Simvastatin Sumatriptan Tamsulosin Topiramate Zolpidem Zolpidem 10mg 5mg 875mg 30mg 1mg 250mg 10mg 50mcg 75mcg 100mg 300mg 600mg 100mg 500mg 60mg 60mg 20mg 30mg 40mg 10mg 20mg 300mg 0.5mg 20mg 100mg 0.4mg 100mg 10mg 5mg $3.22
$2.85
$22.72
$288.96
$17.78
$7.77
$3.97
$212.51
$209.89
$12.05
$9.99
$20.42
$12.78
$24.02
$78.65
$32.67
$4.92
$8.24
$20.35
$5.99
$5.99
$8.11
$47.73
$3.88
$23.21
$70.26
$36.02
$3.41
$3.34
$18.92
$12.16
$33.83
$301.19
$194.40
$18.46
$12.59
$263.77
$241.33
$19.78
$33.33
$42.50
$216.35
$169.00
$148.18
$39.08
$24.28
$28.66
$49.62
$18.29
$18.44
$12.31
$129.23
$11.81
$156.00
$203.60
$174.22
$17.62
$17.62
$15.70
$9.31
$11.11
$12.23
$176.62
$10.69
$8.62
$51.26
$31.44
$7.73
$23.34
$22.08
$203.57
$144.98
$69.53
$6.41
$19.36
$20.42
$29.27
$12.30
$12.45
$4.20
$81.50
$7.93
$132.79
$133.34
$138.20
$14.21
$14.28
Sources of Revenue As you can see, the difference between the sources of revenue is huge. Traditional PBM’s can charge a small administration fee because of how they generate profit in other areas. Transparent PBM’s only have one source of income, the administration fee. Traditional PBM Sources of Revenue
10%
22%
47%
Administration Fee
Mail Order "Spread"
Retail "Spread"
21%
Rebate Retention
Transparent PBM Sources of Revenue
Administration Fee
100%
SourcesofRevenue‐Visual
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Understanding Drug Tiers Drug tiers are groupings of drugs on your prescription benefits formulary1. Each tier has a different copayment. Tier one normally is lower priced brand name drugs. Tier two is a moderate cost drug with higher copay. This tier can include multi‐source and newly generic drugs. Tier three is the highest copayment and is usually single source brand name drugs. A number of factors are considered when classifying drugs into tiers. Cost of the drug and drugs in the same therapeutic class2 can be part of determining the tier. Availability of over‐the‐counter alternatives, certain clinical and economic factors can also influence which tier the drugs fall into. A traditional PBM, will also sign agreements with drug manufacturers to place their drugs in certain tiers. There is an actual instance when an independent pharmacist called a PBM to find out about the tier of a medication. When he asked how a medication becomes a Tier one drug, he was given the following answer – “A medication is considered a Tier one drug when the manufacturer of the medication signs an agreement with the plan.” In all actuality, this means the manufacturer of the medication gives the plan money every time if it is dispensed then it is a Tier one drug. Fortunately, with Lakeview PBM Solutions, you are in control of the formulary and tiers. You have the sole discretion in assigning drugs to certain tiers and in moving drugs from tier to tier. We will provide you with a suggested formulary and tier make‐up but there is no financial motivation to place drugs in a certain tier with us.
1
A formulary is a list of prescription drugs that are preferred by your plan. Therapeutic classes are a way of classifying medical drugs according to their functions.
2
UnderstandingTiers
Transparency Questions to Consider Here are some questions that might be helpful to consider in looking at a Prescription Plans or to include in the Request for Proposal for your prescription plan. They will help get to the heart of transparency, and protect your funds. 1. Will your current PBM quantify savings? 2. Does the PBM Program allow for a fully customized plan that includes individualized formularies that can be modified at any time, by the Client? a. If so, please elaborate, b. Is there a charge to individualize formularies? 3. Does the PBM program provide instant, real‐time claims data and reports, accessible to the Client any time from our desktop computers? 4. Does the PBM program provide the ability for the Client to monitor prior authorization data in real‐time? 5. Will the PBM train Client staff on provided software at no cost? 6. Is PBM prescription drug plan transparent and pass‐through? 7. Is there a price differential between the amount billed to the Client and the amount paid to the pharmacy for generic drugs? 8. Is there a priced differential between the amount billed to the Client and the amount paid to the pharmacy for brand drugs? 9. What is the maximum allowable cost (MAC), expressed as a percentage off all available generics? 10. What percentage of all drug rebate funds received by the PBM will be passed through to the Client? 11. Will the PBM program provide an audit trail on 100% of all funds received from pharmaceutical companies on request? TransparencyIssuestoConsider
Real stories of PBM’s and the games they play 
PDS Industry Message Board Express Scripts sure does have it figured out (Jason Turner 2/29/12) “Got a rejection today from esit for a U‐Care of MN patient (farmed out portion of Medicaid)…the drug was levofloxacin 500mg #10, Formulary alternative = Avelox! They rejected the generic that typically costs less than $10 for one that adjudicated for $171.”  PDS Industry Message Board – Another direct to patient program (Jeff Kline 2/16/12) Astra Zeneca is going to sell Arimidex (Anastrozole) direct to patients for $40 a month. Mighty kind of them, considering that every pharmacy in the US can likely buy it for less than $10.00. The "service" is being provided through Express Scripts, who, according to my calculations stands to make a profit of around $35 a Rx (if they buy at our pricing).  PDS Industry Message Board – Another direct to patient program (Jim Lehan 2/16/12) “The worst mail order fleecing I have ever seen was through Medco. Patient got approval for Qty 180 Ondansetron and at AWP ‐ 65% it cost the plan about $2,000 for a $50 drug. Ouch”  Email from David Moll 3/21/12 “I have experience with MEI and ODS health plan. They refused to pay the higher Mylan Fentanyl price because other mfrs were lower. In talking to the plan, they said they paid $368. My reimbursement was $178. Hmmm….transparent????”  PDS Industry Message Board – One More for PUTT‐Caremark FEP… (Steve Burney 2/16/12) “Last month one of my good customers (Medco Part D insurance) come in on a Saturday morning with an unopened envelope from Medco mail order. She did NOT order anything from them or authorize them to send her anything. She asked me to open it, so I did. Inside were #90 HCTZ 12.5 and a bill for $10 and some change. She asked me what she should do, so I told her her options were to keep it and pay the bill; keep it and not pay the bill, then claim she never received it; or send it back. She chose to pay the $2 to send back this uninvited package she didn’t want. Now, last weekend, it was time to refill her medication. It rejected, refill too soon, with the message that it was filled at MY pharmacy and the refill date was in April. I knew that wasn’t right so I called Medco. I about fell over when they told me, “She got it mail order. Oh wait, here in the notes it says, ‘unsolicited return’, and it is scheduled to be destroyed.” Hmmmm. Why was it not reversed I asked. They finally did reverse it and I was then able to fill it. I was, and still am, upset because if I were to fill a prescription for someone who didn’t request it, then destroy, and not reverse the claim, I would probably be fined, sent to jail, and banned from participation in any government program EVER. Who do WE complain to about such FRAUD, WASTE, and ABUSE??”  PDS Industry Message Board – One More for PUTT‐Caremark FEP… (David McGowan 2/16/12) “A recently widowed customer called upset because the mail order called her days after the funeral and told her she had to switch to mail order now that her husband was gone. She had no clue what to do…they should be ashamed of themselves.” RealstoriesofPBMsandthegamestheyplay
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 PDS Industry Message Board – One More for PUTT‐Caremark FEP… (David Wells 2/16/12) “ESI‐Tricare is doing the same thing. I had a patient who is retired from the US Navy bring his prescriptions in for refills. We tried to run them through and all denied due to “Mail Order”. I asked the patient if he requested his medications to be mailed. He stated someone had called him but he told them no he would get his medications from his pharmacy. I contacted the Dr.’s office to find out what happened. The nurse pulled his chart with a fax from ESI‐
Tricare that stated patient requested that all his maintenance medication be filled by ESI Mail Order. I asked the nurse did she verify that with the patient? She said no we get several requests a day from Medco, Caremark, Humana, and ESI and just assumed that is what the patient wants and don’t have time to verify with the patient.  PDS Industry Message Board – Another Direct to Patient Program…(Waldemar Carlstrom 3/9/12) The worst mail order fleecing I have ever seen was through Medco. Patient got approval for Qty 180 Ondansetron and at AWP – 65% it cost the plan about $2,000 for a $50 drug. Ouch.  PDS Industry Message Board – Alarmed About CVS Caremark…(Kevin Christians 3/6/12) “I was perusing the MI State contract. MI State can audit Caremark’s records, at their own expense, but cannot audit…agreements with vendors, pharmaceutical manufacturers, or distributors, participating pharmacies, or other providers of products or services to the PBM.” This is an example of how their lengthy contracts bury information that you should know.  Third‐Party Newsline (of Paas National) March 2012 – Inappropriate RX Transfer Steering Plan Sponsors are required to provide patients with a Model Transfer Letter prior to transferring a patient’s prescription away from your pharmacy to a mail‐order or other “preferred” pharmacy. Unfortunately, they don’t always play by the rules. Furthermore, patients are sometimes deceived in to thinking that they have to transfer their prescription in the letter. This is called “inappropriate prescription transfer steering”, and everyone in the pharmacy should be educated to help your patients understand that they can JUST SAY NO! Some plans have also allegedly violated rules that prohibit them from making outbound calls to patients to transfer their prescription. When the patient says “no”, they persist, thus harassing the patient until they concede, due to the high pressure tactics that are used. Finally some patients have had their prescription transferred without any notification whatsoever, or because the PBM tried to circumvent the rule by calling their doctor for a new prescription.  Newsletter of PAAS’ View: Express Scripts…April 2012 PAAS View: Express Scripts is Looking out for Shareholders – Not Patients In comments from the Express Scripts Fourth Quarter Earnings Call, George Paz, CEO, made an assumption that narrowing networks and driving more patients to mail order does not decrease access to pharmacist services or compromise outcomes. Paz states that by saving a dollar a script times a million scripts, “All we’ve done is put $1 million into our shareholder’s pockets. That seems like a pretty smart thing to me. I don’t laugh at $0.10 and $0.15 a script, and especially when you start talking a $1 script.” Paz also states that, “drugs are drugs and it shouldn’t matter that much who is counting to 30.” With Paz’s comments on saving $1 a script times a million scripts resulting in $1 million for shareholders RealstoriesofPBMsandthegamestheyplay
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– will anyone take notice that there was no mention of any savings going back to the employer or consumer? Just a few months prior, Medco’s CEO, David Snow, compared pharmacists to robots. The proposed merger between Express Scripts and Medco is not a good deal for consumers or employers. It is not about patient care, controlling true costs in health care, or the value pharmacists provide in monitoring drug therapy and advising patients on important issues such as drug interactions, adherence, or side effects. It’s about the extra million dollars for shareholders. Has either of these companies compared a robot’s ability to interact with and evaluate patient drug therapy issues? What about costs to consumers or the health care system of not receiving a medication on time, missing doses, shipping meds before the patient needs them or continuing to mail discontinued medications? Current research demonstrates that retail community pharmacies generic dispensing rates are at least 10% higher than that of mail order. The average brand name drug price in 2012 was $166.61, compared to just $44.14 for a generic, so there’s a lot to be said for community pharmacies looking out for consumer costs. The top three prescriptions benefit programs, including Express Scripts and Medco, have nearly quadrupled their profits in the last three years – from $900 million to more than $3.5 billion. These corporate behemoths saw nearly a 400% increase in their profits at the expense of consumers struggling to make ends meet, while the average pharmacy profit in the last three years has gone up roughly 14.6% ‐ maybe enough to cover inflation. RealstoriesofPBMsandthegamestheyplay
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MAIL ORDER MAIL ORDER: FACTS AND STATISTICS 
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




When offered maintenance medications through community and mail order pharmacies on a benefit‐equivalent basis, commercially insured employees and their dependents utilized the community pharmacy channel more frequently by a margin of more than 4 to 1 in terms of claims PMPY. Overall allowed charges per claim for community and mail order pharmacy did not significantly differ1. Mandatory mail order drug plans create 3.3 times more waste than prescription drug plans that allow patients the freedom to purchase their prescription drugs at a community pharmacy2. This high rate of waste implies that patients using mail order pharmacies are purchasing in bulk more than what they intend to consume, creating the increased potential risk of overuse and abuse in the future due to the stockpiling of old prescription drugs. Prescription drugs are only of value to patients when taken. Patient compliance with prescription drugs diminishes when patients use a mail order pharmacy due to less access with a face‐to‐face consultation with a pharmacist. A recent study conducted by NCPA for patients enrolled in the Fight4Rx network had found that a large number of patients had problems receiving their medications via mail on time, often having to rely on their local community pharmacist to make an emergency fill. Adherence cannot occur unless the patient has the actual drug. Pharmacy benefit managers (PBMs) gain “rebates” from pharmaceutical manufacturers when they choose to favor their brand name drugs. There have been numerous lawsuits against these PBM’s for illegally switching patients onto more expensive brand name drugs through their mail order pharmacies, so that these PBMs can maximize their rebates.3 Widespread perception of lower prices via mail‐order versus community pharmacy has contributed to the growth of mail‐order pharmacy use despite a lack of evidence of cost savings for pharmacy benefit sponsors4. Generic dispensing ratios are lower in mail‐order than in community pharmacy. (This in turn, causes a higher bill for employers.) 1
Khandelwal, N., Duncan, I., Rubinstein, E., Ahmed, T., & Pegus, C. (2012). Community pharmacy and mail order cost and utilization for 90‐day maintenance medication prescriptions. Journal of Managed Care Pharmacy, 18(3), 247‐255 2
Halberg, D., Smith, E., Sedlacek, K., (2000). Effect of mail‐order pharmacy incentives on prescription plan costs. University of Arkansas for Medical Sciences College of Pharmacy, October 2000. 3
Balto, David. “Ongoing Federal and State Litigation Regarding Pharmacy Benefit Managers.” February 2008, http://www.ncpanet.org/pdf/leg/pbmlitigationfeb08.pdf 4
Johnsrud, M., Lawson, K., Shepherd, M.D., (2007). Comparison of mail‐order with community pharmacy in plan sponsor cost and member cost in two large pharmacy benefit plans. Journal of Managed Care Pharmacy, 13(2), 122‐134 MailOrder:FactsandStatistics
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Differences in pricing of generic drugs between mail‐order and community pharmacy appear to contribute to higher unit costs for generic drugs via mail‐order. Mail order prescriptions can be less effective for patients, especially when exposed to environmental heat, such as temperatures found in mailboxes5. A former employee (Waldemar Carlstrom) of a mail order facility had this to say…”I worked mail order for eight years and yes they are cheaper than retail, but the savings are not passed on to the customer. We created our own cost of drugs for the customer. We could tell the customer we would give them cost minus 35 percent. We did not tell them that we raised their cost from our $10 to over $30 for them and then take the 35 percent off from the $30. Mail order pharmacy is a great business. Take vacation when you want, take a lunch, and even get breaks. It was the best job I ever held. In mail order you can bill the customer and get paid before you even mailed the drugs to the patients! 5
Mail order drugs tainted by heat. (2005). USA Today Magazine 133(2717) 3. MailOrder:FactsandStatistics
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MAIL ORDER WASTE This is a real‐life example of mail order waste that was brought in to Lakeview Pharmacy to be disposed of. Below is a table listing the quantity and retail cost of the medication. Also listed is how long this supply of medications would have lasted the patient. Drug Name/Strength Qty Size Pill Cost Retail Cost Days Supply Aggrenox 25mg/200mg 120
Amlodipine Bes. 5mg 360
Amoxicillin 500mg 180
Furosemide 40mg 90
Klor‐Con M10ER 270
Levothyroxine 112mcg 180
Losartan 50mg 360
Metformin 500mg 450
Nexium 40mg 90
Verapamil 120mg 1534
60
90
500
100
100
100
90
100
500
500
$4.87
$0.15
$0.38
$0.18
$0.58
$0.39
$2.32
$0.33
$7.47
$1.12
Total $583.39
$55.77
$68.97
$16.00
$156.93
$70.66
$833.42
$149.27
$672.12
$1723.89
$4330.42
120 180 180 90 270 180 180 150 90 767 Notice that days supply is all well over the 90 days for 80 percent of the medications. The Verapamil is enough to last over two years! MailOrder–Waste
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This is a real‐life example of mail order waste that was brought in to Lakeview Pharmacy to be disposed of. Below is a table listing the quantity and retail cost and average wholesale price of the medications. DRUG Diovan 150/12.5 Prednisone 10mg Singulair 10mg Zetia 10mg Metoprolol 25mg Simvastatin 10mg Citalopram 20mg Theophylline ER 600mg
Nasonex 17g Xopenex 1.25mg Xopenex 0.63mg Astelin 30ml Spiriva 18mcg Advair 250/50 MailOrderWaste2–August2012
QTY AWP RETAIL 270
90
90
180
360
180
180
389
6
11 ½
7 ½ 1
4
7
Total
$1078.32
8.01
565.67
482.10
97.20
507.62
433.35
763.10
855.12
2056.77
1341.37
105.24
1156.16
1961.68
$11,411.71
$1154.69 12.00 509.10 491.86 45.00 347.15 238.30 715.80 920.33 2284.90 1497.96 127.03 1169.80 1966.56 $11,480.48 Page1
This is a real life example of mail order waste that was brought into Lakeview Pharmacy. They had to dispose of the medications even though they were not expired. The chart below lists the average wholesale price and the retail value of these medications. DRUG Metformin 850mg Levothyroxine 137mcg Tricor 145mg Crestor 10mg QTY AWP RETAIL 279 90 90 30 Total $333.91
36.50
572.87
182.98
$1,126.26
$183.90 65.36 623.96 197.62 $1,070.84 MailOrderWasteex.3July2012
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PBMs Love Automatic Mail Order These drugs are from a patient in California. He did not understand how to take his prescriptions properly. The pharmacist told him to bring them all in and he would go through them with him. This is what he brought in. $28,000 in prescriptions that he had received on auto refill from mail order. Medications that he didn’t need, but the Plan kept paying for! Mail Order Waste – TRICARE/ESI
$6660
“Imitrex injections received from military mail order. Patient called mail
order multiple times to cancel order, but continued to get
medications. Patient died and spouse received order after death.”
*These are actual images sent by participating pharmacies in the Dispose My Meds Program. Patient information has been removed
or obscured to comply with all applicable laws protecting personal health information.
Mail Order Waste
$30,000 from one patient
*These are actual images sent by participating pharmacies in the Dispose My Meds Program. Patient information has been removed
or obscured to comply with all applicable laws protecting personal health information.
Mail Order Waste – Caremark
$14,844 = 17 month supply
*These are actual images sent by participating pharmacies in the Dispose My Meds Program. Patient information has been removed
or obscured to comply with all applicable laws protecting personal health information.
Mail Order Waste – Medicare/Medicaid
“These were all
returned for a dualeligible patient who
passed away. In the
wastebasket are expired
products. We salvaged
what we could and
donated the ones in the
trash bag to a local free
clinic.”
*These are actual images sent by participating pharmacies in the Dispose My Meds Program. Patient information has been removed
or obscured to comply with all applicable laws protecting personal health information.
Pharmacists Forced to Throw Out $30K in Auto‐Refilled Prescriptions From the Times Union COHOES — John McDonald will have to send more than $30,000 worth of unopened and expired mail‐order prescription drugs and medical supplies off to Texas to be incinerated. And it makes him sick to have to do it. "Look at this waste. It's unbelievable," said McDonald, an owner of the family business, Marra's Pharmacy, who is also mayor of Cohoes. He had never seen anything like it in 25 years as a pharmacist. Family members of a deceased man in his late‐60s, a retired county worker who was not a Marra's customer, recently brought in dozens of bottles of pills, insulin, boxes of diabetic test strips and other supplies to treat diabetes, hypertension, kidney disease and allergies. McDonald feared such medical waste may be a hidden epidemic, underscoring a lack of oversight that contributes to spiraling medical care costs, particularly from mail‐order pharmaceutical companies that use automatic refill programs that are hard to cancel. In the $30,000 case, the patient appeared to have little or no co‐pay so there was no incentive to stop shipments of drugs he wasn't using. Moreover, the cost was being passed along to taxpayers for the patient, who was a public servant. In the patient's mind, the pile of drugs and medical supplies that piled up were thought to be "free." "The solution to this kind of problem is complicated, but it's becoming more prevalent than we ever imagined," said McDonald, who learned of a woman who died in Cohoes a few months ago. She had thousands of dollar’s worth of unused mail‐order diabetic test strips and medical supplies. A relative wanted to know what to do. Destroy it was the only option, McDonald said, since strict laws regulate such products. As part of an earth‐friendly environmental initiative, Marra's has taken in old and unused prescriptions as a public service for the past two years. It ships the material at Marra's expense, in special containers to a Texas company that destroys the items. Typically, customers arrive with two or three old, partially‐empty drug bottles at a time. But the outsized drop‐off from family members of the deceased man – whose identity was withheld by McDonald due to privacy regulations — caused McDonald's seven staff pharmacists to gather around in wide‐
eyed amazement. Nearly all of the dozens of bottles of pills and piles of boxes of medical supplies came from a large web‐
based mail‐order company, informedRx. "It's really disturbing and it indicates there's a lot of waste in the system," said Eileen Wood, vice president of pharmacy for Capital District Physicians' Health Plan, or CDPHP. The deceased man was not a CDPHP client. "This is not the first time we've seen this and we're concerned," Wood said. "It's a big problem with pharmacy operations that do automatic shipping. Once they've got your prescription, they just keep shipping and shipping on auto‐refill and you can't stop it. It's like a robot gone wild." Pharmacists Forced to Throw Out 30K in Mail Order Waste
When they've tried to help customers stop automatically shipped drugs, McDonald said he and other pharmacists at Marra's have found it can be difficult to contact the mail‐order companies to do so. McDonald speculated that this is likely the scenario that led to the $30,000 pile of taxpayer‐paid medical supplies that will be destroyed. "Seeing all this waste was eye‐opening and shocking," said Kathleen Bonner, an intern at Marra's who will graduate this spring from the Albany College of Pharmacy. She tallied the inventory, including 54 boxes of Flonase, a nasal spray for allergies, at more than $100 per box. "It reminded me that there needs to be monitoring and personal intervention by a pharmacist," Bonner said. "This man needed care he wasn't getting. Obviously, he was non‐compliant because none of the drugs had been opened." McDonald and Bonner discussed, with an overtone of irony, that a pharmacist's mantra is to stamp out FWA: fraud, waste and abuse. "This isn't fraud," McDonald said. "But it is waste and it's definitely abuse for taxpayers who paid for it." [email protected] • 518‐454‐5623 • @PaulGrondahl Pharmacists Forced to Throw Out 30K in Mail Order Waste
All About Repackaging To understand repackaging, you must first understand what an NDC number is. Each drug is given a National Drug Code number, otherwise known as an NDC number. The first four digits represent the manufacturer/company code. The last two digits are the package size and everything in between is the code for the drug and the strength. The chart below is a partial list showing different prices on the different NDCs for Nexium 20mg. Keep in mind that only one company, Astra Zeneca, makes Nexium. They have six different NDC numbers. The remaining NDCs are repackaged NDC numbers. Repackaging typically occurs when a company buys a large bottle of a prescription medication such as Nexium, and makes it into smaller bottle sizes. So, if a company buys a 1000 count bottle of Nexium and simply divides it into 10 bottles of 100, this is repackaging. The new bottle of 100 is given a new NDC and a new price. The price is at the discretion of the re‐packager. As you can see above, the prices of these repackaged Nexium’s range from $4.49 to $14.61 per capsule. An even bigger problem (as if the repackaging wasn’t enough) is that most drug pricing for consumer plans are based on AWP minus a certain percentage. When you purchase drugs through mail order, you will not know if the AWP they are using in the formula is the $4.49 or the $14.61 or something in between. Traditional PBMs will not share this information with you. Truly transparent PBMs such as Lakeview PBM Solutions, will. REBATES All About Rebates The following were quoted by Dave Marley in an article for Forbes regarding the ESI merger. March 22, 2012  Consequences of the ubiquitous use of rebates “Plan sponsor receive only a very small portion of the rebates negotiated by PBMs. The rest goes straight to PBM profits. Plan sponsors often make the mistake of thinking they received a break on drug prices through rebates.” This is misleading, though, because the rebate system contributes to the rise in prices year to year. “Manufacturers are shrewd, large, and powerful. They are not going to simply give away rebate dollars.” 
Hypothetically how would you feel about a ban on rebates completely? It ”would ultimately benefit plan sponsors and consumers.” and it “would mean that drugs would survive in the market based on their value and the benefits they confer, not because of back‐door partnerships between manufacturers and pharmacy benefit managers.” 
FTC deliberations regarding the merger. “The merger should be rejected. In an industry already rife with abuse and lacking any transparency, an increasingly consolidated market would only harm consumers, plan sponsors and pharmacists.” 
Walgreen’s: “They can survive” a falling out with Express Scripts, but “only because Walgreens’ outsized market share and revenue streams give it the luxury of terminating bad contracts. Independent pharmacies don’t have an option – and consolidation among the largest PBMs will only make the problems worse.” Another quote from Dave Marley, March 30, 2012 
“When PBMs talk about negotiating lower drug prices, what they are really talking about are rebates, and ultimately raise drug costs, not lower them.” 
While it may sound counter‐intuitive, the use of rebates is actually an important factor in rising drug costs. Manufacturer rebates paid to PBMs for preferential formulary placement ultimately drive drug costs up while contributing to PBM and manufacturer profits. 
Here’s how rebates work: Typically, pharmacy benefit managers keep the majority of the rebate dollars from manufacturers while passing on small “discounts” to plan sponsors. To avoid losing money through rebates, drug manufacturers simply raise the price of a drug year after year to recoup the cost of the previous year’s rebate. That rise in cost is often much higher than any “discount” PBMs passed on to plan sponsors the year before. So the rebates that are supposedly saving consumers’ money are instead lining the pockets of the PBMs and increasing drug costs year after year. AllAboutRebates
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Confused by rising medication costs?
Watch out for the rebates
BY DAVE MARLEY
April 2, 2012
There’s no doubt that across the country, prescription drug costs are on the rise. A recent report from the AARP showed that brand name prescription drugs used by millions of older Americans grew at nearly four times the rate of inflation from 2005 to 2009 – and the trend didn’t stop in 2009. According to independent pharmacists, brand name drug prices are as high as they have ever been. Every benefits manager knows the importance of offering employees a plan that makes prescription drug prices affordable. Benefits managers should take a careful look at the common practices of their pharmacy benefit manager to understand the PBM’s use of manufacturer rebates. While it may sound counter‐intuitive, the use of rebates is actually an important factor in rising drug costs. While it would be reasonable to think that rising ingredient costs or increased research and development might justify a price increase to important medications, the real reason for price increases is much less palatable. Manufacturer rebates paid to PBMs for preferential formulary placement ultimately drive drug costs up while contributing to PBM and manufacturer profits. Here’s how it works: Typically, pharmacy benefit managers keep the majority of the rebate dollars from manufacturers while passing on small “discounts” to plan sponsors. To avoid losing money through rebates, drug manufacturers simply raise the price of a drug year after year to recoup the cost of the previous year’s rebate. That rise in cost is often much higher than any “discount” PBMs passed on to plan sponsors the year before. So the rebates that are supposedly saving consumers’ money are instead lining the pockets of the PBMs and increasing drug costs year after year. If the plan sponsors are going to pay higher and higher drugs cost each year, they should be getting every penny of the manufacturer’s rebates and incentives paid to the PBM. For benefits managers, it’s important to understand how rebates work and talk to your PBM to find out exactly how big a portion of manufacturer rebates the PBM retains and how much is passed on to plan sponsors and consumers. About the Author
Dave Marley
Dave Marley is the President of Pharmacists United for Truth and Transparency (PUTT) an independent watchdog organization dedicated to exposing the role Pharmacy Benefit Managers (PBMs) play in driving up prescription drug costs for consumers and employers. PUTT is a growing coalition of independent pharmacists and pharmacy owners and a resource for employers, policy makers and members of the media. It is a not‐for‐profit organization funded by individual members, not corporations or other special interest groups. For more information, visit TruthRx.org BRAND/GENERIC PRICING Lipitor and the Generic Game If you are one of the many people taking Lipitor to control your cholesterol, you may finally be seeing some relief in the price of your monthly prescription. Technically, Lipitor went generic in October of 2011, but despite this, many pharmacy benefit managers (commonly known as PBMs) still preferred the brand Lipitor. Even though your physician may have written your prescription for Atorvastatin, the generic of Lipitor, this may have been ignored and you were still receiving the brand ‐ at the brand price. From November 2011 to May 2012, there was only one company allowed to make the generic. Since more companies are now manufacturing the generic, the price should begin to fall even more. But, the question remains – Why would the PBM still prefer the brand, and more expensive choice, if a generic was available? Many plans claimed it was because supplies of the drug were limited, but maybe it was due to the rebates the PBMs were receiving from Pfizer (the manufacturer of Lipitor). It would not be the first time that a PBM preferred a brand due to rebates they receive from the manufacturer. It happens often. In fact, some of the brands will give the PBM rebates or price breaks, to be the preferred drug on the formulary. And, some PBMs will make Atorvastatin a preferred brand drug on their formulary. This will also keep the price up. According to the Wall Street Journal, there are five retailers, including Walgreens that have filed a class action lawsuit against Pfizer for allegedly using “anticompetitive tactics to delay the introduction of competing generic copies of Pfizer's blockbuster cholesterol‐lowering pill Lipitor.” The same article in the Wall Street Journal alleges that, “Pfizer's arrangements with PBMs forced purchasers to buy more brand‐name Lipitor at higher prices—and less lower‐priced generic versions—than they would otherwise have bought.” It seems very clear that there are some alarming and unethical practices going on. Several additional branded medications will have generics available this year including Plavix, Singulair, and Seroquel. Consumers should become informed of what kind of pricing their pharmacy plan has. They should also be asking their doctors to write their prescriptions for the generics, to save money on their drug spend. The plan sponsor can also look into switching to a transparent PBM to manage their pharmacy benefits. With a transparent, full‐disclosure PBM like Lakeview PBM Solutions, the rebates are completely pass‐
through and are not kept by the PBM. Therefore, they have no potential for financial gain through rebates. They are truly looking for the best rates for their plan and plan users. Citations: Loftus, Peter. "Pharmacies Sue Pfizer Over Lipitor." Wall Street Journal [New York] 07 07 2012, U.S. B3. Print. Early, Denise. "Health." The Tucson Citizen.com. N.p., 14 Jul 2012. Web. 19 Jul 2012. <http://tucsoncitizen.com/medicare/2012/07/14/lipitor‐generic‐available‐is‐your‐part‐d‐saving‐you‐
money/>. JUNE MARKS IMPORTANT TRANSITION FOR BRAND NAME DRUGS BENEFITS PRO
June 18, 2012
For years, Plavix and Lipitor, two of the most lucrative prescription medications in the history of the American drug market, have constituted quite a one‐two punch. Now, as Plavix loses its patent protection and Lipitor faces competition from multi‐source generics, it’s an important time for consumers and benefits managers to understand how the transition from brand to generic will affect drug prices going forward. As Pharmacists United for Truth and Transparency explained on AARP’s Inside E Street, Pfizer previously offered massive rebates to pharmacy benefits managers (PBMs), the third party administrators of prescription drug programs, to give preferential formulary treatment to brand name Lipitor. In doing so, Pfizer and a number of PBMs kept brand name Lipitor profitable and expenses higher than needed for many employers and consumers. PBMs readily accept manufacturer rebates since their opaque contracts with employers often allow the PBM to keep a majority of the rebates as profit while passing only a small portion onto the employer. PBMs are notorious for crafting contracts that grant themselves maximum financial flexibility and make employers vulnerable to overpaying for prescription drugs. One contract between a pharmacy benefit manager and an employer states that the PBM has the right “to make an equitable adjustment to the rates, guarantees, administrative fees and/or Rebates” when “Rebate revenue is materially decreased because Brand Drugs move off‐patent to generic status.” Any benefit manager who signs such a contract is essentially giving their PBM the green light to retain high drug prices for drugs that have transitioned from brand to generic. Now, Lipitor and Plavix, which have helped provide massive profits for drug manufacturers and PBMs, face increased competition from cheaper generic drugs. Benefits managers who expect to see significant reductions in their PMPM (per member per month) claims should take a careful look at drug costs now that Lipitor, Plavix and other profitable drugs lose patent exclusivity. It stands to reason that as consumers take less expensive drugs, employer costs would also plummet. But the powerful and profitable PBM industry won’t allow employers to reduce costs without a fight. If employers aren’t careful, PBMs will overcharge employers for generics – keeping drug costs rising when they should be going the other direction. About the Author Jason Wallace Jason Wallace is Vice‐Chairman of the Board of Pharmacists United for Truth and Transparency (PUTT), an independent watchdog organization dedicated to exposing the role Pharmacy Benefit Managers (PBMs) play in driving up prescription drug costs for consumers and employers. PUTT is a growing coalition of independent pharmacists and pharmacy owners and a resource for employers, policy makers and members of the media. It is a not‐for‐profit organization funded by individual members, not corporations or other special interest groups. For more information, visit TruthRx.org MISCELLANEOUS PBM ARTICLES Providing Better Access to Prescription Drug Benefits By Peter Ciaramita, Lakeview PBM Solutions As a pharmacist who has been in the industry for more than 30 years, I have seen how rising prescription costs have led to some tough choices for both consumers and employers. There has been much discussion nationally about the tactics used by traditional pharmacy benefits managers (PBMs). A PBM is the middleman between pharmacies and insurance companies. Employers hire PBMs to negotiate drug prices with manufacturers and handle the exchange of money between pharmacies and health plan enrollees. The relationship is meant to make it easier and more affordable for employers to offer prescription drug benefits, but it has evolved into a complicated and confusing process that severely limits access for consumers. Traditional PBMs have taken advantage of the system and the effect has been detrimental to consumers, employers and the pharmacy industry. This unregulated, multibillion dollar industry controls prescription health plans for more than 200 million Americans. The lack of transparency and complex methods used to overcharge for prescription drugs allows these PBMs to hide real drug costs from their clients. One way they do this is with spread pricing. In spread pricing, the PBM negotiates lower rates with the pharmacy network but does not pass on these lower rates to the employer. It’s not an illegal practice, but it does provide for a lack of transparency. This situation has been able to happen because traditional PBMs typically don’t provide clients with complete, itemized billing statements. While consumers are struggling, large PBMs continue to increase their profits. This is unacceptable. It’s time to get back to the basics with a transparent process that is fair for all. Pharmacists from across the country are standing up for change in the prescription drug process. Pharmacists United for Truth and Transparency (PUTT) is a national coalition of more than 900 pharmacists and pharmacy owners formed to expose the unjustifiably high prices of prescription drugs set by traditional pharmacy benefit managers. PUTT also created the website truthrx.org to assist in informing consumers of what is really happening. As a result of this call for change, a new wave of transparent PBMs are launching across the country including Lakeview PBM Solutions here in Racine. Transparent PBMs are fair, ethical, and designed to provide affordable benefits to both the employers and employees. There are no hidden markups and rebates, network discounts and incentives are fully passed through to the client. Cost saving proof is at the employers’ fingertips with easy to use software. Benefit managers can access up to the minute data to see exactly how much their company is paying for prescription benefits. Transparent PBMs are straightforward, streamlined and aiming to take the guesswork out of a complicated issue. It is my goal to educate and inform consumers and employers that there are better choices available. The process doesn’t have to be complicated. I urge you to take the time to learn more about transparent PBMs and see if you can benefit from this new, transparent business model. Peter Ciaramita is a pharmacist and business owner in Racine. He owns and operates Lakeview Pharmacy and recently launched Lakeview PBM Solutions in an effort to provide employers and their employees easier access to prescription drug benefits. Prescription Benefits ‐ What’s it Really Costing You? By Peter Ciaramita, Lakeview PBM Solutions Pharmacy Benefit Managers (PBMs) have been in the news of late, specifically, the proposed merger between two of the country’s largest PBMs, Express Scripts and Medco. At issue is what this potential merger could mean for employers and consumers. On the one hand is the belief that it could expand service offerings and reduce costs. Others are of the opinion that it will lead to higher prices, inferior service and a lack of prescription drug access because of preferred networks and forced mail order. As a pharmacist who has been in the industry for more than 30 years, I have seen how the tactics used by traditional PBMs have caused higher prescription costs and a lack of choices for employers and consumers. Therefore, I am of the opinion that traditional PBMs have misaligned their mission and goals with client needs and this merger would be harmful to employers and consumers alike. PBMs are the middleman between insurance companies and pharmacies. Employers hire PBMs to negotiate drug prices with manufacturers and handle the exchange of money between pharmacies and health plan enrollees. PBMs were meant to make it easier and more affordable for employers to offer prescription drug benefits, but it has evolved into a complicated and confusing process that severely limits access for consumers. The problem lies in the lack of transparency and complex methods used by traditional PBMs. This largely unregulated, multibillion dollar industry controls prescription health plans for more than 200 million Americans and often results in overcharging for prescription drugs. This happens with a common practice known as spread pricing. In spread pricing, the PBM negotiates lower rates with the pharmacy network but does not pass on these lower rates to the employer. Traditional PBMs typically don’t provide clients with complete, itemized billing statements that disclose, in a transparent manner, the true costs of the drugs provided to the client’s employees. The good news is that employers and employees have a choice in this matter. Pharmacists from across the country have been standing up for change in the prescription drug process through a national coalition called Pharmacists United for Truth and Transparency. More than 900 pharmacists and pharmacy owners formed the coalition to expose the unjustifiably high prices of prescription drugs set by traditional pharmacy benefit managers. As a result of this call for change, a new wave of transparent PBMs are launching across the country. These transparent PBMs, by their design, are a fair and ethical solution to the complicated issue of prescription benefits. Employers and benefit managers who use transparent PBMs have a better understanding of what their company actually pays in providing benefits to their employees and have better access to that data. It is my goal to educate and inform consumers and employers there are better choices available. The process doesn’t have to be complicated. I urge you to take the time to learn more about transparent PBMs and see if you can benefit from this new, transparent business model. Peter Ciaramita is a pharmacist and business owner in Racine. He owns and operates Lakeview Pharmacy and recently launched Lakeview PBM Solutions in an effort to provide employers and their employees easier access to transparent prescription drug benefits. GETMOREFROMYOURPHARMACYBENEFITMANAGER
BYDAVEMARLEY
March19,2012
FormanyHRmanagerstheworldofpharmacybenefitmanagers,thethird
partyadministratorsofprescriptiondrugprograms,isunderstandably
confusing.Butwithmorethan200millionAmericansreceivingdrug
coveragefromaPBM,therearefewdecisionsforbenefitsmanagersmore
importantthanchoosingandmanagingaPBMthatwillensurereliable
coverageandgoodpricesforemployersandconsumers.
Butwheretostart?PBMcontractsareoftenriddledwithlanguagethat
makesfeestructuresconfusingandjargonthatmakesitdifficulttodiscernwhatyou’reactually
payingfor.But,justlikewithanyothercontractor,youshouldknowexactlywhereyourmoneyis
going.Inpart,thePBMmodelreliesonHRmanagersnotaskingthetoughquestions.Butfor
starters,youcanensuretransparencybetweenyourcompanyandyourPBMbymakingsureyou
havewritten,understandableanswerstothesethreequestions:
Canyouprovideadetailed,itemizedexplanationofyourfeestructureandschedule?
Thisquestionwillhelpyouunderstandexactlywhatyou’repayingforandhelpyoumakesureyou
aren’tbeingchargedmark‐upsondrugpricesthatwillgostraighttothePBM’sprofits.
Doyouusethesamebenchmarksincalculatingpricetoclientsandpaymentstopharmacies?
PBMshavebeenknowntochargeemployersahigherpriceforsomedrugsthantheyreimbursethe
pharmacies.Whentheydo,the“spreadprice”differenceismoneyfromyourcompany’sbottomline
goingstraighttothePBM.
CanIreviewacopyofyourcontractwithnetworkpharmacies?
MakesureyouknowwhatthepharmaciesarehearingfromthePBMtoo.Thiswillhelpensure
responsibilityandtransparencyanddiscouragethePBMfrommarking‐updrugcosts.
IfthePBMwon’tagreetoshowyouacopyofnetworkpharmacycontracts,there’sagoodchance
there’ssomethingthePBMistryingtohide.BydemandingcompletetransparencyfromyourPBM,
you’reholdingthemtotheirendofthebargain.TodootherwiseissimplyaskingforthePBMto
takeyourmoneyandrun.
AbouttheAuthor
DaveMarley
DaveMarleyisthePresidentofPharmacistsUnitedforTruthandTransparency
(PUTT)anindependentwatchdogorganizationdedicatedtoexposingtherole
PharmacyBenefitManagers(PBMs)playindrivingupprescriptiondrugcostsfor
consumersandemployers.PUTTisagrowingcoalitionofindependent
pharmacistsandpharmacyownersandaresourceforemployers,policymakers
andmembersofthemedia.Itisanot‐for‐profitorganizationfundedbyindividual
members,notcorporationsorotherspecialinterestgroups.Formore
information,visitTruthRx.org
Shedding Light on the PBM Game Written by Dave Marley Taken from BenefitsPro April 30, 2012 Pharmacy benefits managers, third party administrators of prescription drug programs, are entering increasingly into a tricky game that sounds eerily familiar to anyone who was ever bullied by an older brother or sister. In recent years, PBMs have transitioned to a system in which they incentivize pharmacies to dispense brand‐name drugs, which are generally much more expensive than their generic counterparts. In turn, prescription drug prices for plan sponsors and consumers continue to rise while the PBMs pocket the profits. For benefits managers, it’s especially important to be aware of the ways in which PBMs are capable of manipulating drug pricing. By understanding the PBM business model, you’ll be better informed to ask the tough questions during contract negotiations and ensure that your contract is 100 percent transparent. You should be able to say with confidence that the money you’re giving to the PBM is no greater than the amount the PBM gives the pharmacist. But, that’s rarely how it actually works. Here’s a textbook example of how a PBM arbitrarily changes the reimbursement rate for a pharmacy between generic and a brand‐name drug, ultimately leads more consumers to brand‐name drugs, and consequently to higher co‐pays and premiums in the long term. Many large PBMs push increased use of brand‐name medications since manufacturers provide the PBM with rebates for preferential formulary placement. While the PBM passes on a small “discount” to consumers, they keep the majority of rebate dollars for themselves. But even as plenty of highly profitable brand‐name drugs lose their exclusivity in 2012, PBMs will invoke another trick to ensure their profit margins aren’t affected. As cheaper, generic drugs become available, PBMs will overcharge plan sponsors for the medication, hiding a price mark‐up confusing terms like “ingredient costs” that cannot easily be verified. Then, they’ll reimburse the pharmacies at the absolute minimum level – ensuring their own profits from the “spread” pricing. For the PBMs, business has never been better. Huge profits on generics thanks to spread pricing and huge profits on brands thanks to manufacturer rebates. Heads, I win; Tails, you lose. It’s time we all shed some light on the game. ABOUT THE AUTHOR Dave Marley Dave Marley is the President of Pharmacists United for Truth and Transparency (PUTT) an independent watchdog organization dedicated to exposing the role Pharmacy Benefit Managers (PBMs) play in driving up prescription drug costs for consumers and employers. PUTT is a growing coalition of independent pharmacists and pharmacy owners and a resource for employers, policy makers and members of the media. It is a not‐for‐profit organization funded by individual members, not corporations or other special interest groups. For more information, visit TruthRx.org PBM ad campaign misleads consumers
BY DAVE MARLEY
May 21, 2012
The Pharmaceutical Care Management Association just launched an advertising campaign that would make
Mad Men’s Don Draper and other spin doctors proud. It’s an age‐old strategy: if you can’t win the fight,
dodge the question and change the subject.
The PCMA is the industry trade group for pharmacy benefits managers, third party administrators of
prescription drug programs. Recently, PBMs have come under fire for operating in a system that lacks
transparency and driving up employers’ drug costs. Independent and chain pharmacy organizations advocate
for legislation that would help reduce the cost of medication by limiting pharmacy benefits managers’ ability
to mark‐up prices and overcharge employers. Now, the PCMA’s advertising campaign (It’s the Drugstore Lobby vs. Employers) has baselessly turned pharmacists into the villains, accusing them of trying to “force
businesses to pay more for prescription drugs.”
Benefits managers often work with PBMs to administer their company’s prescription drugs. Choosing and
managing a PBM contract is frequently a difficult, confusing process which can leave employers on the wrong
end of a bad deal. For benefits managers, it’s important to understand the ways in which pharmacy benefits
managers can drive up prescription drug costs – and costs to your company. The misleading language the
PCMA uses in its advertising campaigns is the same as the devious sales pitch the PBM representatives give to
benefits managers.
Pharmacy benefits managers routinely claim their contracts are credentialed and legitimate. But at the same
time, they’re unwilling to allow pharmacists and employers to communicate about how much employers are
paying for a medication and how much the pharmacy receives. So what are they hiding? Often, pharmacy
benefits managers mark‐up the cost of the medication and bill the employer for “ingredient cost,” a
fabricated term used to disguise the price increase. It’s a classic example of a middleman driving up costs
and taking home the profit. And once benefits managers catch on to the standard PBM tricks, there’s not an
ad campaign in the world that will save them.
About the Author Dave Marley Dave Marley is the President of Pharmacists United for Truth and Transparency (PUTT) an
independent watchdog organization dedicated to exposing the role Pharmacy Benefit
Managers (PBMs) play in driving up prescription drug costs for consumers and employers.
PUTT is a growing coalition of independent pharmacists and pharmacy owners and a resource
for employers, policy makers and members of the media. It is a not‐for‐profit organization
funded by individual members, not corporations or other special interest groups. For more
information, visit TruthRx.org
WEBSITE Website How‐To’s You can use our website, www.lakeviewpbm.com, to check your co‐pay amount, find a pharmacy near you, see plan details, or formulary listings. Follow the steps below. If you do not find what you are looking for, just give us a call, and we will be happy to help. FIND A PHARMACY NEAR YOU Whether you are at home, or out of town, there is a pharmacy in our network waiting to fill your prescriptions. 1. Go to www.lakeviewpbm.com – there will be a rotating picture with different services we offer on the homepage. 2. Click on MEMBER in the black navigation bar. The screen below will appear. Type your MEMBER ID number from your card in the Cardholder ID box and click Login. WebsiteHow‐To’s
Page1
3. You are now logged in to the Member’s Only section of the website. You will see the screen below. This is where you will go to find the member specific information. Above the Member Access heading you will find the buttons to navigate with. 4. The first screen contains the Plan Specific information as you can see on the right. It also gives you the link to the mail order service website. WebsiteHow‐To’s
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5. Click on the Formulary Listing button located in between Plan Information and Drug Price Calculator. This will bring you to the Formulary. The formulary is a list of prescription drugs, both generic and brand name, that are preferred by your health plan. 6. The next button is Drug Price Calculator. Click on to find the cost and co‐pay for your prescription. that 7. To find the cost, enter the drug name and quantity. A drop down menu will appear for you to pick the strength. Once you have chosen the strength, then click get price. WebsiteHow‐To’s
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8. The results will give you the cost, the tier the drug is in, the copay, and IF there is a generic available as pointed out in figure A. This drug does not have a generic or therapeutic substitution. (See Figure B for generic example.) Figure A The drug you searched for The cost of the drug The price you pay (your copay) Generic information if available WebsiteHow‐To’s
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Figure B 9. This feature is most likely the one you would use most often. The last button is Pharmacy Locator. This will be useful if you are out‐of‐town or away from your usual pharmacy. There are 63,000 pharmacies in the network. WebsiteHow‐To’s
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10. To use the Pharmacy Locator simply put in the zip code and choose how many miles out you would like, or need, to go. 11. The pharmacies within the parameters chosen by you that are in the network will be displayed. If you ever need any help or cannot find what you are looking for on the website, please just give the help desk a call. WebsiteHow‐To’s
Page6
Pharmacy Locator – How To (Non‐Member) At the Home screen, click on News in the navigation bar. In the News screen on the right hand side, click Pharmacy Finder under Provider Locations. PharmacyFinderNon‐Member
Page1
A pop‐up window will appear. Enter the zip code and radius, then click Locate. The results will be listed below the search fields. Scroll down for complete results. PharmacyFinderNon‐Member
Page2
WELLNESS Wellness Site In addition to the convenience of the web portal, your employees will have access to a health and wellness site. This site provides resources for a variety of health topics. Monthly, a newsletter is posted to keep members informed on current health issues. WellnessSite
Page1
WellnessSite
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REPRICING Pete Ciaramita 517 Wisconsin Avenue Racine, WI 53403 262‐995‐9660 www.lakeviewpbm.com DATA REQUEST FOR REPRICING, PLAN ANALYSIS
AND PLAN DESIGN
Here is a list of the fields needed for our Data Request for Plan Performance Assessment. Ideally we request a full data dump of actual claims data for the most recent twelve (12) month period and the number of covered lives, but will work with whatever you can get. The ideal data elements include the following (minimally the bolded/italicized items): Date of Fill
Rx Number
NDC
Drug Name
Strength
Quantity
Days’ Supply
Brand, Generic, or MAC
Mail/Retail
Patient I. D.
Sex
DOB
Person Code (1, 2, 3, 4, etc.)
Usual & Customary
AWP
Dispensing Fee
Total Submitted
Ingredient Cost Allowed
Dispensing Fee Allowed
Total Allowed
Co-Pay
Total Plan Amount Paid
Price Type Code (U&C, AWP, MAC)
Formulary
DataRequestforRepricing
3/27/12
Page1
Data Request For Repricing, Plan Analysis And Plan Design
Warnings that your PBM is hiding something
1. PBM provides requested data:
 with truncated NDC numbers
 with no NDC numbers
 with missing date of service
 that is incomplete, with missing fields that you requested
 that is summary only, no specifics
2. PBM requests a large fee to release your data
3. PBM says they will charge a fee per covered life to work with a different PBM
Page 2
Re-pricing Example A
Incumbent PBM
Formulary
Retail Brand
Retail Generic
Total
RX COUNT
AWP
INGREDIENT COST
DISPENSE FEE
TAX
GROSS COST
MEMBER COPAY
PLAN COST
AWP DISC
$
$
$
$
$
$
$
AVE COST / RX
47,524
8,031,080.77
5,617,378.97
57,682.50
5,675,061.47
483,095.57
5,191,965.90
30%
$
$
$
$
$
$
$
$119.41
11,032
2,324,541.20
1,984,276.01
15,712.50
1,999,988.51
157,048.99
1,842,939.52
15%
$
$
$
$
$
$
$
$181.29
25,382
2,025,495.43
964,043.88
36,442.50
1,000,486.38
192,923.94
807,562.44
52%
Formulary
Mail Brand
Mail Generic
$
$
$
$
$
$
$
$39.42
2,644
1,776,128.74
1,426,022.04
58.50
1,426,080.54
43,490.95
1,382,589.59
20%
$
$
$
$
$
$
$
$539.36
Non-Formulary
Retail Brand
Retail Generic
4,028
809,827.63
351,283.97
76.50
351,360.47
30,801.37
320,559.10
57%
$
$
$
$
$
$
$
$87.23
3,617
731,504.51
625,036.84
5,059.50
630,096.34
49,761.91
580,334.43
15%
$
$
$
$
$
$
$
$174.20
225
34,449.35
10,784.34
319.50
11,103.84
1,468.01
9,635.83
69%
Non-Formulary
Mail Brand
Mail Generic
551
315,737.75
249,908.11
12.00
249,920.11
7,184.90
242,735.21
21%
$
$
$
$
$
$
$
$49.35
45
13,396.16
6,023.78
1.50
6,025.28
415.50
5,609.78
55%
$
$
$
$
$
$
$
$453.58
$133.90
RxSense by DataRx
Formulary
Retail Brand
Retail Generic
Total
RX COUNT
AWP
INGREDIENT COST
DISPENSE FEE
TAX
GROSS COST
MEMBER COPAY
PLAN COST
AWP DISC
$
$
$
$
$
$
$
AVE COST / RX
47,524
8,031,080.77
4,978,386.17
80,422.00
5 058 808 17
5,058,808.17
483,095.57
4,575,712.60
38%
$
$
$
$
$
$
$
$106.45
11,032
2,324,541.20
1,950,725.13
20,952.00
1 971 677 13
1,971,677.13
157,048.99
1,814,628.14
16%
$178.72
GENERIC UTILIZATION
62%
TRANSPARENT PRICE SAVINGS
$
Savings %
REBATE ESTIMATE TO PLAN
$
$
$
Total Potential Savings %
2,644
1,776,128.74
1,507,994.65
5,136.00
1 513 130 65
1,513,130.65
43,490.95
1,469,639.70
15%
$572.29
$
$
$
$
$
$
$
4,028
809,827.63
192,036.73
6,246.00
198 282 73
198,282.73
30,801.37
167,481.36
76%
$49.23
$
$
$
$
$
$
$
3,617
731,504.51
580,329.06
6,700.00
587 029 06
587,029.06
49,761.91
537,267.15
21%
$162.30
$
$
$
$
$
$
$
225
34,449.35
7,214.05
336.00
7 550 05
7,550.05
1,468.01
6,082.04
79%
$33.56
Non-Formulary
90 Day Retail Brand
551
315,737.75
253,093.76
1,070.00
254 163 76
254,163.76
7,184.90
246,978.86
20%
$
$
$
$
$
$
$
90 Day Retail Generic
$
$
$
$
$
$
$
$461.28
45
13,396.16
2,639.41
64.00
2 703 41
2,703.41
415.50
2,287.91
80%
$60.08
For every 1% increase in Generic Utilization the net drug spend typically goes down by 2%.
Potential Spread (the difference between the PBM pharmacy contract and the plan contract, typically retained by the PBM).
121,186.20
Rebate estimate based on data provided.
81
81,218.40
218 40
Mandate generic use when available in the class or the patient pays the difference
difference.
1.4%
Savings %
TOTAL POTENTIAL SAVINGS
$20.66
$
$
$
$
$
$
$
Non-Formulary
Retail Brand
Retail Generic
90 Day Retail Generic
2.1%
Savings %
THERAPEUTIC SUBSTITUTION
25,382
2,025,495.43
484,353.38
39,918.00
524 271 38
524,271.38
192,923.94
331,347.44
76%
90 Day Retail Brand
10.9%
Savings %
GENERIC SWITCH
616,253.30
$
$
$
$
$
$
$
Formulary
595,324.67
Savings Example: Potential savings converting Crestor, Lipitor, Nexium, Prevacid, and Tricor to a generic in the same therapeutic class.
10.5%
$
1,413,982.57
24.9%
9% of claims were processed through mail order
Prescription Re-Pricing Summary Report 2011
EXHIBIT B
Incumbent PBM
Total
RX COUNT
AWP
INGREDIENT COST
DISPENSE FEE
GROSS COST
MEMBER COPAY
PLAN COST
AWP DISC
$
$
$
$
$
$
AVE COST / RX
47,825
9,800,080.21
5,808,707.42
44,115.87
5,852,823.29
522,393.85
5,330,429.44
41%
Retail Brand
Single Source
Multi-Source
$
$
$
$
$
$
$122.38
8,375
2,110,594.53
1,721,949.68
9,027.02
1,730,976.70
145,031.25
1,585,945.45
18%
$
$
$
$
$
$
$206.68
1,041
121,949.01
98,862.59
1,083.07
99,945.66
14,013.97
85,931.69
19%
Retail Generic
Single Source
Multi-Source
$
$
$
$
$
$
$96.01
938
143,753.05
74,710.70
1,029.60
75,740.30
9,348.64
66,391.66
48%
$
$
$
$
$
$
$80.75
22,825
1,859,859.22
572,723.24
24,822.56
597,545.80
172,679.45
424,866.35
69%
Mail Brand
Single Source
Multi-Source
$
$
$
$
$
$
$26.18
5,144
3,432,791.16
2,691,075.09
2,770.11
2,693,845.20
98,569.71
2,595,275.49
22%
$
$
$
$
$
$
$523.69
697
177,589.62
130,188.31
307.63
130,495.94
10,648.26
119,847.68
27%
Mail Generic
Single Source
Multi-Source
$
$
$
$
$
$
$187.23
146
43,826.06
24,122.84
112.99
24,235.83
1,265.55
22,970.28
45%
$
$
$
$
$
$
8,659
1,909,717.57
495,074.97
4,962.89
500,037.86
70,837.02
429,200.84
74%
$166.00
$57.75
RxSense by DataRx
Total
RX COUNT
AWP
INGREDIENT COST
DISPENSE FEE
GROSS COST
MEMBER COPAY
PLAN COST
AWP DISC
AVE COST / RX
$
$
$
$
$
$
47,825
9,800,080.21
5,436,555.61
66,358.00
5,502,913.61
522,393.85
4,980,519.76
45%
Retail Brand
Single Source
Multi-Source
$
$
$
$
$
$
$115.06
8,375
2,110,594.53
1,687,699.64
16,750.00
1,704,449.64
145,031.25
1,559,418.39
20%
$203.52
GENERIC UTILIZATION
68%
TRANSPARENT PRICE SAVINGS
$
Savings %
REBATE ESTIMATE TO PLAN
$
$
938
143,753.05
66,440.45
1,876.00
68,316.45
9,348.64
58,967.81
54%
$72.83
$
$
$
$
$
$
22,825
1,859,859.22
448,133.17
45,650.00
493,783.17
172,679.45
321,103.72
76%
$21.63
$
$
$
$
$
$
5,144
3,432,791.16
2,661,490.35
2,661,490.35
98,569.71
2,562,920.64
22%
$517.40
$
$
$
$
$
$
697
177,589.62
99,395.04
99,395.04
10,648.26
88,746.78
44%
$142.60
$
$
$
$
$
$
146
43,826.06
20,143.69
20,143.69
1,265.55
18,878.14
54%
$
$
$
$
$
$
8,659
1,909,717.57
384,377.58
384,377.58
70,837.02
313,540.56
80%
$137.97
For every 1% increase in Generic Utilization the net drug spend typically goes down by 2%.
Potential Spread (the difference between the PBM pharmacy contract and the plan contract, typically retained by the PBM).
88,476.25
Rebate estimate based on data provided.
103,035.52
Savings Example: Mandate generic use when available in the class or the patient pays the difference.
1.9%
$
Savings %
POTENTIAL SAVINGS
$68.16
$
$
$
$
$
$
Mail Generic
Single Source
Multi-Source
1.5%
Savings %
THERAPEUTIC SUBSTITUTION
1,041
121,949.01
68,875.70
2,082.00
70,957.70
14,013.97
56,943.73
44%
Mail Brand
Single Source
Multi-Source
6.0%
Savings %
GENERIC SWITCH
349,909.68
$
$
$
$
$
$
Retail Generic
Single Source
Multi-Source
556,496.57
Savings Example: Potential savings converting Crestor, Lipitor, Nexium, and Tricor to a generic in the same therapeutic class.
9.5%
$
Potential Savings %
1,097,918.03
18.8%
ADMINISTRATION FEE
$
143,475.00
TOTAL POTENTIAL SAVINGS
$
954,443.03
31% of prescriptions filled were through mail order
$44.39
CONTRACTS 517 Wisconsin Avenue Racine, WI 53403 262‐995‐9670 www.lakeviewpbm.com MUTUAL NONDISCLOSURE AGREEMENT THIS AGREEMENT is made on the date set forth below between DATA‐Rx Management, Inc., at 6070 Southard Trace, Suite 220, Cumming, GA, 30040 and the Other Party that has signed below. The parties intend to engage in discussions, during the course of which each may receive from the other, or have access to, information that is confidential and of great value to the other. This information may include data and know‐how, whether or not in writing and whether or not disclosed before or after the execution of this Agreement, concerning the disclosing party’s business, technologies, plans, properties, or financial affairs, including similar data or know‐how of or about its existing and prospective affiliates, suppliers, creditors, customer, employees, and independent contractors, as well as any information concerning the willingness of the disclosing party or its affiliates to engage in negotiations between the parties, and the fact that disclosures of confidential information are being made. All such information, including any and all materials embodying any of the information, whether disclosed orally or otherwise and whether or not marked, “Confidential” or “Proprietary,” shall be considered by the recipient and its employees, affiliates, advisers, and independent contractors as proprietary and confidential (Proprietary Information”). In order to facilitate both the disclosure of information and any resulting negotiations and in consideration for having access to or receiving Proprietary Information, each of the parties agrees as follows: 1. Protection of Proprietary Information. a. Neither party will use for any purpose any part of the Proprietary Information of the other, except to evaluate the matters under discussion between the parties. b. Each party will use the same efforts to protect the confidentiality of the other’s Proprietary Information as it uses to protect its own Proprietary Information. c. Neither party will make copies of the Proprietary Information, except as necessary to assist its evaluation of the matters under discussion. MutualNondisclosureAgreement
March 28, 2012 Page1
517 Wisconsin Avenue Racine, WI 53403 262‐995‐9670 www.lakeviewpbm.com d. Neither party will disclose or disseminate, or permit any of its employees, affiliates, advisers, or independent contractors (altogether its “Agents”) to disclose or disseminate, any part of the Proprietary Information of the other to any third party without prior written consent. Each party receiving Proprietary Information of the other shall be permitted to disclose it only to a limited group of the recipient’s Agents on an “as needed” basis to further the goals of the business discussions between the parties. Each party acknowledges that it is responsible for insuring that its Agents and their respective employees, affiliates, adviser, and independent contractors who are given access to the other party’s Proprietary Information will be informed and directed to conduct their activities in accordance with the terms of this Agreement. e. The undertakings and obligations of a party under this Agreement shall not apply, however, to any information which that party can establish to have: (1) become publicly known through no action on the part of that party or its Agents, (2) been known by that party prior to the receipt from the other, or (3) become available to that party on a non‐confidential basis from another source which represented at the time that it was entitled to disclose it. 2. Return or Destruction of Materials. Upon termination of business discussions or any resulting business relationship between the parties, or otherwise at any time at the request of the other, each party shall (a) deliver to the other all files, documents, and other media (and all copies and reproductions of any of the foregoing) in its possession or control which contain any of the other’s Proprietary Information, including any notes or other materials made by or for the receiving party and containing any of the Proprietary Information and/or (b) shall destroy all such files, documents, and other media (and all copies and reproductions thereof) and certify in writing to the other that it has done so. 3. Disclosure Required by Authorities. If a receiving party is requested or required by governmental or judicial authorities (by oral questions, interrogatories, requests for information or document, subpoena, civil investigative demand, or similar process) to disclose any information supplied to that party by the other, it MutualNondisclosureAgreement
March 28, 2012 Page2
517 Wisconsin Avenue Racine, WI 53403 262‐995‐9670 www.lakeviewpbm.com is agreed that the receiving party will provide the other party with prompt notice of any such request or requirement so that the other party may seek an appropriate protective order and/or waive the receiving party’s compliance with the provisions of this Agreement. It is further agreed that if, in the absence of a protective order or the receipt of a waiver hereunder, the receiving party is nonetheless, in the opinion of its counsel, compelled to disclose Proprietary Information of the other under penalty of contempt or other penalty or liability, the receiving party may disclose that Information without liability hereunder, to the extent required to avoid the penalty or liability. 4. Enforcement. It is understood and agreed that money damages would not be a sufficient remedy for any breach of this Agreement by a receiving party or its Agents, and that the other party shall be entitled, without the posting of a bond, undertaking, or other security, to seek injunctive relief as a remedy for any such breach. That remedy shall not be the exclusive remedy for any such breach or threatened breach, but shall be in additions to all other remedies available at law or equity. 5. Matters Binding and Not Binding. Unless (and only to the extent) expressly superseded by a writing signed by both parties, this Agreement is the entire agreement of the parties relating to its subject matter and shall bind the parties for a period of three years from the date set forth below. By disclosing Proprietary Information as contemplated by this Agreement, the disclosing party is not representing or warranting the accuracy or completeness of it. Any representation or warranty concerning the Proprietary Information or any other matters will be set forth in a later agreement. This Agreement does not continue an offer to engage in any specific transaction or relationship, nor does it obligate either party to execute any definitive agreement relating to any particular matter. Either party may terminate discussions, disclosures, and negotiations prior to the execution of any further agreement without incurring liability to the other party except for the express provisions of this Agreement (which shall continue in effect). 6. Miscellaneous. This Agreement shall be governed by and construed in accordance with the laws of the State of Texas, without reference to any choice of law principles. Failure or delay by a party in exercising any right, power, or privilege MutualNondisclosureAgreement
March 28, 2012 Page3
517 Wisconsin Avenue Racine, WI 53403 262‐995‐9670 www.lakeviewpbm.com hereunder shall not operate as a waiver thereof, nor shall any single or partial exercise preclude any further exercise or the exercise of any right, power, or privilege hereunder. This Agreement may be executed in any number of counterparts, and each such counterpart shall be an original and all such counterparts shall constitute but one agreement. Execution of a copy of this Agreement by one party and execution of a different copy by the other party shall constitute sufficient execution so long as a copy of each party’s signature is delivered to the other party. Delivery by a party of a copy of this Agreement containing the party’s signature which is conveyed by facsimile, photo static or similar method to the other party or its counsel shall be sufficient for purposes of execution and delivery of this Agreement by that party. If legal action s is required to enforce any provision of this Agreement, the costs of enforcing that provision, including but not limited to court costs and reasonable attorney’s fees and expenses, shall be assessed upon the party against whom the enforcement was obtained and the enforcing party shall be entitled to recover those costs as part of the enforcement proceeding or, in that party’s discretion, in a later proceeding. IN WITNESS WHEREOF the parties have executed this Mutual Nondisclosure Agreement as of the _________ day of _________________________, 20_____. DATA‐Rx Management, Inc. ________________________________ (Other Party Name) By: _______________________________ By: ______________________________ Name: _____________________________ Name: ____________________________ Title: ______________________________ Title: _____________________________ Address: __________________________ __________________________________ __________________________________ MutualNondisclosureAgreement
March 28, 2012 Page4
PRESCRIPTION DRUG PROCESSING AGREEMENT
This Agreement (this "Agreement") is entered into by and between______________________, of _____________________________, hereinafter referred to as “Client”, and Lakeview PBM Solutions LLC of 517 Wisconsin Ave., Racine, WI 53403, hereinafter referred to as “Lakeview PBM". WHEREAS, Lakeview PBM is in the business of, among other things, providing pharmaceutical benefits management, pharmacy claims processing and related services (the “Lakeview PBM Prescription Drug Processing Services”), as described herein and more fully in the Plan Setup set forth as Exhibit A, which is attached hereto and incorporated herein by reference; WHEREAS, Client has agreed to utilize the Lakeview PBM Prescription Drug Processing Services; and, WHEREAS, Lakeview PBM and Client desire to set forth their agreement relating to the Lakeview PBM Prescription Drug Processing Services which Client desires to utilize; NOW THEREFORE, for and in consideration of the mutual promises, covenants and conditions contained herein, the parties agree as follows: 1. TERM. This Agreement is entered into the date it is executed by both parties ("Effective Date").This Agreement shall become effective on the Effective Date, and shall continue until either party terminates by providing the other party with ninety (90) days prior written notice of such termination, and upon the date set forth in said notice of termination, this Agreement shall terminate. 2. SCOPE OF AGREEMENT, FEES AND TERMS, BILLING, AND DELINQUENCY. Lakeview PBM shall provide Client with the Lakeview PBM Prescription Drug Processing Services described on Exhibit A, and Client shall pay said services in the manner described on Exhibit A. The parties agree that the determination of fees to be paid to Lakeview PBM for the services provided pursuant to this Agreement, the terms of payment and billing for those fees, and the handling of delinquent payments, are set forth on Exhibit A. 1|Drug Processing Agreement
3. COMPLIANCE WITH ALL LAWS AND CONTRACTS. Client and Lakeview PBM shall each comply with the provisions of all applicable federal, state, and local laws, ordinances, regulations, rules, and codes, including, without limitation, the Health Insurance Portability And Accountability Act (HIPAA) Privacy and Security Rules and the federal Health Information Technology for Economic and Clinical Health Act (the “HITECH Act”), as well as any laws, ordinances, regulations, rules, and codes relating to the handling and/or processing of pharmaceutical claims and the information contained in such claims, in fulfillment of their obligations under this Agreement. Each party’s obligations pursuant to this paragraph shall survive any termination of this Agreement. 4. NOTICES. It is mutually agreed that all notices required or permitted under this Agreement shall be in writing and shall be deemed to have been properly given or served and shall be effective when either delivered by personal service; delivered by telecopy or overnight mail; or, deposited in the United States Postal Service, postpaid via registered or certified mail with return receipt requested to the following addresses or to such other addresses as may be designated. To Client: To Lakeview PBM Solutions LLC: ________________________ Peter J. Ciaramita ________________________ President ________________________ Lakeview PBM Solutions LLC ________________________ 517 Wisconsin Ave. ________________________ Racine, WI 53403 5. NONDISCLOSURE OF TERMS AND CONDITIONS. Except for disclosures required by law, Client agrees and acknowledges that: (a) this Agreement, together with its specific terms and conditions, including but not limited to pricing terms and conditions, shall not be disclosed to any person or entity not a party to this Agreement, other than the employees, accountants and attorneys of Client, (b) Client shall take measures to ensure that the employees, accountants and attorneys of Client having access to this Agreement shall not disclose this Agreement or any of its parts to any person or entity not employed by Client. The obligations of Client pursuant to this paragraph shall survive any termination of this Agreement. 6. UNDERSTANDINGS, COMMITMENTS, AND AGREEMENTS, WHETHER ORAL OR WRITTEN. THE PLAN SETUP IS SUBJECT TO ACCEPTANCE BY CLIENT AND LAKEVIEW PBM AND BY REFERENCE HEREWITH SHALL SPECIFICALLY BE INCORPORATED AS PART OF THIS AGREEMENT. THIS AGREEMENT AND THE PLAN SETUP MAY NOT BE RELEASED, DISCHARGED, CHANGED, OR MODIFIED EXCEPT BY AN INSTRUMENT IN WRITING, DULY EXECUTED BY EACH PARTY HERETO. 2|Drug Processing Agreement
IN WITNESS WHEREOF, the signatories executing this Agreement on behalf of Client and Lakeview PBM hereby represent and warrant that they have full power and authority to enter into and bind their respective entities and each of the parties has so directed its representative to cause this Agreement to be executed on its behalf by its duly authorized officer, as of the day and year written below. ___________________________________ Lakeview PBM Solutions LLC (insert name of Client) By: By: Print Name Peter J. Ciaramita President Title Title Print Name Date Signed Date Signed _________________ Effective Date 3|Drug Processing Agreement
Exhibit A, Plan Setup for:
________________________
August 13, 2012
Presented by:
Pete Ciaramita
RxSense Plan Design Setup Checklist
This checklist focuses in on the areas that will affect the overall performance of your plan. It is
intended to allow the plan sponsor (employer) to customize their plan design to facilitate their goal
achievement. A Lakeview PBM Solutions, LLC plan design expert is available to assist in this process,
but ultimately the plan sponsor has the ability and sole authority to drive the plan design, co-pay
structure, medication coverage, restrictions, and pharmacy access that will provide the benefit their
employees need at a price they can afford. It is critical that each area is reviewed, choices indicated,
signed and forwarded to Lakeview PBM Solutions, LLC at least two weeks prior to the expected start
date.
Client Information
Include
Request
New
Existing
Input
Client Name
RxSense PCN (Lakeview PBM Use Only)
New Plan Name
New Group Number(s)
Effective Date
Number of Covered Employees
Number of Covered Lives
Primary Membership Residency
Major Medical Carrier
Client Demographics
Include
Option
Option
Client is a Covered Entity under HIPAA
Union Status
Union
Non – Union
Combination
Member Mix
Active
Retirees
Combination
Plan Type
8/13/2012
MC
340B
LTC
Hospice
RxSense Plan Setup Sheet: Initial Acceptance _______________
SNF
Other
Page 2
Contact Information
Client Name
Contact Name
Address
City
State
Contact Email
Zip
Contact Phone
Will have access to RxSense Administrator Tool?
Administrator
Enrollment & Eligibility
Reporting
Plan Name
Contact Name
Address
City
State
Contact Email
Zip
Contact Phone
Will have access to RxSense Administrator Tool?
Administrator
Enrollment & Eligibility
Reporting
Broker
Contact Name
Address
City
State
Contact Email
Zip
Contact Phone
Will have access to RxSense Administrator Tool?
Administrator
Enrollment & Eligibility
Reporting
Third Party Administrator
Contact Name
Address
City
Racine
State
Contact Email
Contact Phone
Will have access to RxSense Administrator Tool?
8/13/2012
Zip
Administrator
Enrollment & Eligibility
Reporting
RxSense Plan Setup Sheet: Initial Acceptance _______________
Page 3
Patient Identification Cards
Include
Option
Input
Provided by Other _________________
Provided by user in RxSense
Provided by Lakeview PBM Solutions
Rx Card
Major Medical and Rx Card
Plastic
Glossy Coated Cardstock
BIN
610568
PCN
DRX
Group Number
(TBD)
Patient Identification Number
Plan Assigned
Lakeview PBM Solutions Assigned
Card Shipping
Send Initial Cards to:
Member
Client
TPA
Broker
Additional Cards Provided by:
Data Rx
Client
Send Additional Cards to:
Member
Client
TPA
Broker
Pharmacy Network
Include
Option
Input
DataRx Open Network
Specialty Drug Network - Axium
8/13/2012
(If different - Please attach list or name of
pharmacy)
Mail Order Network – Drug Source
(If different - Please attach list or name of
pharmacy)
Custom Network
(Please attach list or name of pharmacy)
RxSense Plan Setup Sheet: Initial Acceptance _______________
Page 4
Include
Option
Input
340B
(Please attach list or name of pharmacy)
Pharmacy Network Pricing
Include
Option
Input
Retail
Brand: AWP –
15%
Brand Dispensing Fee
$2.00
Generic: AWP –
25% or DRX MAC
Generic Dispensing Fee
$2.00
Brand: AWP –
15%
Brand Dispensing Fee
$2.00
90 Day at Retail
Generic: AWP –
25% or DRX MAC
Generic Dispensing Fee
$2.00
Brand: AWP –
15%
Brand Dispensing Fee
$2.00
Mail Order
Generic: AWP –
25% or DRX MAC
Generic Dispensing Fee
$2.00
Brand: AWP –
25%
Brand Dispensing Fee
$2.00
Specialty
Generic: AWP –
Generic Dispensing Fee
8/13/2012
RxSense Plan Setup Sheet: Initial Acceptance _______________
60% or MAC
$2.00
Page 5
Co-Pays and Deductibles
Include
Option
Amount
Patient Co-Pay at Retail
Tier 1 – Generic
Tier 2 – Preferred Brand
Tier 3 – Non-Preferred Brand
34 days
$
62 days
$
93 days
$
34 days
$
62 days
$
93 days
$
34 days
$
62 days
$
93 days
$
34 days
$
62 days
$
93 days
$
34 days
$
62 days
$
93 days
$
34 days
$
62 days
$
93 days
$
Tier 4 – Preferred Specialty
Tier 5 – Non-Preferred Specialty
Tier 6
Patient Co-Pay Mail Order
Tier 1 – Generic
Tier 2 – Preferred Brand
Tier 3 – Non-Preferred Brand
8/13/2012
Tier 4 – Preferred Specialty
(More than 34 days Not Recommended)
Tier 5 – Non-Preferred Specialty
(More than 34 days Not Recommended)
RxSense Plan Setup Sheet: Initial Acceptance _______________
Page 6
Include
Option
Amount
Tier 6
Maximum Deductible
Per Member
$
Per Family
$
Per Member
$
Per Family
$
Per Member
$
Per Family
$
Plan Maximum
Maximum Out of Pocket
Once Out of Pocket is Met
Zero Co-Pay
Percent Co-Pay
%
Plan Parameters
Include
Option
Limited to:
Paid Claims on Lower of
First Available:
Custom MAC
Provide attached formulary
Data Rx MAC
HCFA MAC
Pricing Parameters
Then:
Usual and Customary
Gross Amount Due
8/13/2012
RxSense Plan Setup Sheet: Initial Acceptance _______________
Page 7
Prescription Edits
Include
Option
Limited to:
15
34
93
Other_______
Limit Days Supply
Repacks Not Allowed
Prescription Quantity Limits
per Calendar Month
per 30 Days
per 90 Days
per 24 Hours
per 365 Days
per Life of the Plan
Qty Limits per Rx
See Attached List
Age Limits (Minimum Age 26)
Dependent Adult Age Limit
Disabled Age Limit
Active DAW
0-No Product Selection Indicated
1-Substitution Not Allowed by Prescriber
2–Patient Requested Product Dispensed
3–Pharmacist Selected Product
4–Generic Drug Not in Stock
5–Brand Drug Dispensed as Generic
6–Override
7–Brand Drug Mandated by Law
8–Generic Not Available in Marketplace
9–Other
Patient Pays Difference
Allow Refill when % Consumed
Max Number of Days to Process a Claim
8/13/2012
Brand vs. Generic
80 % (recommended)
Days (Typically 30)
RxSense Plan Setup Sheet: Initial Acceptance _______________
Page 8
Prior Authorizations
Include
Option
Input
Prior Authorizations
Administered by DataRx
Administered by Plan
Decision Maker
Phone
Email
Lost Medications
Stolen Medication
Dosage Change
Vacation or Travel Supply
Prior Auth Required for Claims Over
$700.00 (Recommended)
Enrollment and Eligibility
Include
Option
Input
Patient Open Enrollment
Patient Closed Enrollment
Member Screen
Managed Care Member Screen
Hospice/340B Member Screen
Required Fields for Submission
Name
Address
Sex
Date of Birth
Initial Eligibility – RxSense
8/13/2012
RxSense Plan Setup Sheet: Initial Acceptance _______________
Page 9
File Type:
Initial Eligibility - Electronic
Delivery Method:
Tab Delimited
FTP
Secure Email
RxSense
Ongoing Eligibility
Electronic data file transfer – Set up FTP
Frequency of Updates
Daily
Specify Date:
Weekly
Specify Date:
Monthly
Specify Date:
Formulary
Include
Option
Input
Open Formulary
Open Formulary w/Exclusions
(see below)
Closed Formulary
Please attach formulary
Ventegra Drug List
Preferred Drug List
Premium
Premium Plus
Hospice
Please attach formulary
Custom
Please attach formulary
Formulary Management
DataRx
Plan Sponsor via Remote Access
Decision Maker
Phone
Fax
Email
8/13/2012
RxSense Plan Setup Sheet: Initial Acceptance _______________
Page 10
Formulary Exclusions and Limits - All Drugs/Therapeutic Classes will
be covered except for the following exclusions and limitations:
Exclude
Include
with Limits
Drug/Therapeutic Category
ADD/ADHD
Limitations
Age 18
No Age Restriction
Anabolic & Androgen Steroids
Experimental Drugs
Blood / Plasma / Blood Products
Anti-Obesity
Contraceptive Patches
Contraceptive Rings
Contraceptive Devices
Contraceptive Implants
Contraceptive Injectables
Oral Contraceptives
Contraceptives - Extended Cycle not
to exceed 93 day supply
Cosmetic Drugs - Acne/Anti-Aging
Age 18
No Age Restriction
Devices
BP Monitor/Nebulizer/Masks/Tubing
Diabetic Medications/Supplies:
Limits/Recommended Qty Limits per 30
days:
Alcohol Swabs
Glucagon
Glucose Monitors -----------------
One/Lifetime
Insulin-----------------------------
30 ml
Insulin Injection Devices
Lancets
Lancet Devices
Test Strips (Blood & Urine)-------
200 strips
Insulin Needles & Syringes
8/13/2012
RxSense Plan Setup Sheet: Initial Acceptance _______________
Page 11
Exclude
Include
with Limits
Drug/Therapeutic Category
Erectile Dysfunction
Limitations
_____ Per Month (Recommend qty. 6)
Fertility
Growth Hormones
Hair Growth
Immunizations / Vaccines
Injectables
Migraine – Injectable
Migraine – Nasal Spray
Per Month (Recommend 9 per month)
Migraine – Oral
Per Rx
(Recommend 9 per Rx)
Needles and Syringes other than
Insulin
Nutritional Supplements
Prenatal
Oral Vitamins - Legend
Food Supplements
Allergy
OTC (Insulin Is A Covered Drug)
G.I.
Vitamins
Limit 90 days per 12 months
Smoking Cessation – Legend
Submitted Price of Prime Ingredient
Submitted Price Plus Fee
Compounds
Price Using Special NDC Drug Price
Maximum Compound Amount
$
Rebate Management
Include
Option
Input
Include Rebate Management
8/13/2012
RxSense Plan Setup Sheet: Initial Acceptance _______________
Page 12
Include
Option
Input
Plan Type
Hospice
Workers Comp
Managed Care
Other
LTC
Open Formulary
Ventegra Preferred Formulary
Closed Formulary
Ventegra Premium Formulary
Ventegra Premium Plus Formulary
Custom Formulary
Other _______________________
Formulary Tiers
2
3
4
5
Co-Pay Differential
Preferred Brand Differential is = or > $15
Member Web Portal
Include
Option
Input
Include Member Web Portal
Plan Overview
Co-Pays
Limits
Formulary Listing
Pharmacy Listing
Reports
Include
Option
Input
Standard
Custom
8/13/2012
$
RxSense Plan Setup Sheet: Initial Acceptance _______________
Page 13
Billing
Include
Option
Input
TPA
Company Name
Address
City
State
Zip
Contact Name
Contact Phone
Contact Email
Per Claim/Admin Fee
$3.00
Frequency of Billing
Monthly
Twice Monthly
Method of Billing
Email
Mail
Pharmacy Paid by
DataRx
Plan Sponsor
TPA
Patient
8/13/2012
RxSense Plan Setup Sheet: Initial Acceptance _______________
Page 14
The client has reviewed the attached Plan Setup. The client understands and agrees to the terms
outlined therein.
_________________________________
Lakeview PBM Solutions, LLC__________
_________________________________
_________________________________
(Client)
(Company Representative)
_________________________________
(Print Name)
(Title)
__________________________________
(Date)
8/13/2012
Pete Ciaramita
President____
__________________________________
(Date)
RxSense Plan Setup Sheet: Initial Acceptance _______________
Page 15