DrFirst, Inc.’s Post

A roundtable discussion at the 2024 Total Pharmacy Solutions Summit had some key takeaways about the impact DIR fees have had on independent pharmacies so far this year. Independent pharmacies continue to be greatly impacted by the changes, however, those that have sought out other revenue opportunities, such as clinical programs, have reduced some of that negative impact. https://lnkd.in/eZrrCF6S #independentpharmacy #EPICPharmacyNetwork

Kudos to Osterhaus pharmacy. Our small private practice offers a dispensary to our cancer patients for specific medications under Montana law. It is convenient, often cheaper, and allows the patient access to personalized care coordination. We must agree to all terms, including the outrageous fees these middlemen take, to provide the medicine. And did I mention that the largest insurance companies own the most prominent middlemen (Pharmacy Benefit Managers, or PBMs)? That's right, they negotiate (and I use that term generously) on the front end with us on what they will pay for the services we provide their members, down to every last item. Their PBMs process the claims, take fees out for their services, and provide rebates back to the insurance companies they contract with, often themselves. Here's a little cherry on top...if the plan is a Medicare Advantage plan, the Government pays them to manage those lives, so the government pays them a rate higher than Medicare, and then they start shaving. Is it any wonder small pharmacies and independent medical groups are disappearing? I would argue patient care suffers the price.

Real-Time Prescription Benefit #RTPB is changing the game when it comes to handling prescriptions. It offers unparalleled drug-price transparency right when it’s needed most, and it fits into the ePrescribing tools doctors already use. Read more about RTPB here: https://lnkd.in/gpH89Stp

Did you know that you can unlock significant savings on prescription medications by enlisting the expertise of an Independent Healthcare Advocate? Check out the steps below for how you, or your advocate, can effectively lower your prescription drug costs... 1. Always call your insurance company first to ask how well your medication is covered and if you can get it for less at another pharmacy. 2. For GENERIC medications... → Look into DISCOUNT PHARMACIES such as Costco, Walmart and others, who can help you pay less WITHOUT using insurance. *Note: Some will offer significant discounts if you sign up for their low cost membership! → Go online to GoodRx and SingleCare for coupons to use at other pharmacies. → Consider Online Pharmacies that offer discounts. Some take insurance (BlinkHealth), and some don’t (Mark Cuban Cost Plus Drug Company). 3. For BRANDNAME medications: → Go to the drug manufacturer’s website and look for copay coupons and assistance programs. → Check out NeedyMeds.org, it has tons of information about assistance programs and discounts. You can search directly by the drug name or even the diagnosis. They're working to make this site even better in 2024. → Get a letter from your doctor and file an appeal with your insurance. In summary, don't ever give up. you have options. Take a look at this video reporting on all of these suggestions, and consider hiring an Independent Healthcare Advocate for all of your health journey needs. Help us spread the word of the work we do and the services we offer. #patientadvocacy #healthcareadvocate https://lnkd.in/g2agbT75

Thank you to fellow pharmacy owner John Seymour for sharing this link with me. If you live in the state of Virginia, I urge you to leave a comment on HB104 (Delegate Wachsmann) – Dispensing Authority What the bill does: ✅ Allows pharmacies to refuse to fill certain prescriptions. ✅ Requires contract between PBM and pharmacy to contain provision allowing pharmacy to refuse to fill prescription for a drug that is reimbursed below the actual cost of medication. Pharmacists don’t want to turn down prescriptions, but if we are continually reimbursed below cost then we will not be able to stay in business to cover our costs, which will directly impact patient access and care by creating more pharmacy deserts. Current PBM contracts are non-negotiable and are opt-out only. As active members of the Virginia Pharmacy Association, we (Henry Ranger, PharmD, RPh and I) support their goals: 💊Transparency in drug pricing, PBM costs and dispensing fees. 💊Reducing costs across all healthcare insurers and payors – including co-insurance and co-pays. 💊Patient access to pharmacy services. 💊Safe work environment for pharmacists and technicians. 💊Growing access to pharmacy and technician training in addition to educational opportunities. We need ALL hands on deck, keep the momentum going and hold PBMs accountable! #StrongerTogetheRx https://lnkd.in/ePQPpmBC

Do you think that expanding specialty pharmacies could be a good strategy for improving and extending patient care? Personally, I see the potential. However, it all depends on successful prescription claims adjudication. “Implementing a specialty pharmacy model is complex... We find that many overlook the resources required to navigate payor approval of prior authorizations or lack needed support to connect patients to programs that help them better afford their out-of-pocket cost of medications," says Mike Brown. When pharmacies don't have the infrastructure to process claims and minimize rejections and denials, it's often just too expensive for patients. If specialty pharmacies want to provide affordable service to people in their community, they need to understand and focus on claims adjudication. #SpecialtyPharmacies #ClaimsAdjudication #PharmaIndustry

Check out what our CTO, Nathan Fornwalt, has to say about the addition of pharmacy benefit investigations and prior authorizations in the eBlu Solutions platform. 💙 "With the launch of our new pharmacy benefit workflow, we are expanding our market-leading platform to include comprehensive pharmacy benefit services. This innovative solution empowers providers with real-time pharmacy insurance eligibility checks, prior authorization, and appeals processing—all within a single, integrated platform. By offering upfront visibility into pharmacy networks and benefit coverage, we eliminate unnecessary delays and confusion that often accompany prescription fulfillment." If you aren't using eBlu for pharmacy benefits, why not? Sound off in the comments below. 👇

A Model for Modern Pharmacy Billing and Payments in Long-Term Care Centers: Pharmacists working with long-term care centers benefit from streamlined billing to support and build patient trust. #finance #pharmacy #lifesciences

It is unfortunate, but true. While brands suffer a significant loss due to their cost, even generic drugs are not reimbursed well. Today, I filled a prescription for Atorvastatin 20mg, a cholesterol medication for a patient who has had a heart attack in the past. This medication prevents them from having another heart attack. The PBM paid us $1.80 for a 30-day supply of this medication, which is barely over the medication cost of $1.07. This amount doesn't even cover the cost of filling the prescription. The cost to fill includes the bottle, label, transmission fees, labor, and expertise. A fair reimbursement would be $16.07, which is the medication cost plus a $15 dispensing fee. You might wonder why people keep saying that the cost of medications is skyrocketing when the PBM only paid us $1.80. The answer to this question is that the PBM then turns to the payer (insurance company) and asks them to pay $40 for the same Atorvastatin prescription. The PBM pockets $38.20.  Over the last decade, the differences in reimbursement versus payments have been increasing exponentially. This has resulted in tighter squeezing of both sides while padding the PBM's bottom line. Eliminate the middleman and the Payer pays only $16.07 for Atorvastatin, instead of $40.

How can a Medicare insurance agent help me understand my prescription drug coverage? I can help you navigate the complexities of prescription drug coverage and will take the time to understand your unique medication needs and budget, then guide you through the different Medicare drug plans available. Together, we can compare formularies (the list of covered drugs), pharmacy networks, deductibles, and copayments to find a plan that ensures you have access to the medications you need at the most affordable cost. I stay up-to-date on annual changes to Medicare plans, so you can feel confident knowing you have accurate information when making coverage decisions. If you have any questions about your prescriptions or how your drug coverage works with other parts of Medicare, Im here to provide clear explanations and support. My goal is to simplify the process, serve as your advocate, and help you secure the best prescription drug coverage for your individual situation. Reach out today for personalized assistance! Need no cost help? Call Sheryl Gulan Lic #19582450