99 / 537
Employer Group ABC
Incurred:
Apr 2014 thru Dec 2015
Paid:
Apr 2014 thru Mar 2016
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3.2.1 Non-PBM Drug Spend
Non-PBM spend on pharmaceuticals is paid by Health Plan, not the PBM. It is therefore included in medical expenses
and usually includes the J-Codes. However, many non-PBM drugs are exceptionally expensive and deserve special
attention. Non-PBM drug spend is often best controlled through the use of contracting Specialty Pharmacy networks.
Figure 3.2.2 shows the total pharmacy spend as seen in chart 3.2.1, now with the non-PBM spend added in.
Figure 3.2.2 Distribution of Pharmacy Spend
(Refer to Figure 3.2.1)
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The top 10 drugs driving non-PBM spend are listed in table 3.2.1, with unit price and utilization values broken out.
Table 3.2.1 Top 10 drugs driving non-PBM spend
35,
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Drug
Current
PMPM
Change in
PMPM
Change in
# Scripts
Change in
Unit Pricing
Norm value
of PMPM
Percent
Rank (Norm
value =
50%)
PHARMACY (ALSO SEE
063X, AN EXTENSION
OF 025X) - GENERAL
CLASSIFICATION
$7.19
3.9%
-13.9%
25.0%
$7.97
-
Pharmacy - Extension
of 025X - Drugs
Requiring Detailed
Coding
$6.00
-13.5%
-8.5%
-2.0%
$1.77
-
Infliximab Injection
$1.82
-17.1%
-21.4%
9.3%
$1.34
-
Injection,
Pegfilgrastim, 6 Mg
$1.48
-13.1%
-27.5%
24.2%
$0.96
-
Rituximab Cancer
$1.40
72.9%
69.6%
5.7%
$0.65
-
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Source: Medical Intelligence : PBM Cost: Claims Module / Pharmacy
Non PBM Cost: Claims Module / Medical / drill by Plan Type / Zoom Forward / drill by Procedure Group / Non-PBM Drug
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Source: Medical Intelligence : Claims module / Medical / Plan Type / Zoom Forward / drill by Procedure Group / Non-PBM Drug / Source
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Norm or Verscend Norm in this report refers to the values from Verscend's Commercial Normative database.