Derek Frye quoted in Medicare Advantage News
Derek Frye, Audit & Compliance Practice Leader, was recently quoted in the article, CMS Issues First Fine for High Rate of IRE Auto-Forwarding, published in the September 7, 2017 issue of Medicare Advantage News. Read a copy of the article here.
Phil DeNucci attends the Midwest Business Group on Health 2017 All Member Summit
Phil Denucci, Market Leader, recently attended the Midwest Business Group on Health's All Member Summit, and participated as a speaker on a panel and roundtable discussion on increasing employee engagement in their benefits.
The Burchfield Group welcomes Tim Foster to its Consulting team
Tim Foster joins The Burchfield Group as Senior Consultant supporting employer, labor & union trusts, government and coalition clients. He will partner with clients through PBM procurement projects and assist them in managing their pharmacy benefit. Tim brings nearly 15 years of PBM account management experience to Burchfield, including extensive experience with large employers and public sector employers.
The Burchfield Group welcomes Sonya Henderson to its Health Plan team
Sonya Henderson joins The Burchfield Group as Practice Leader of the Health Plan market. She supports the strategic and operational needs of health plans to identify and create pharmacy, audit and compliance solutions and coordinate their implementation across the organization. Sonya has close to 30 years of experience working within health plans in the areas of corporate compliance, government programs and operations. Her experience includes Commercial, Medicaid, Medicare and Marketplace products, as well as regulatory and legislative affairs, internal audit, Model Audit Rule compliance, enterprise risk management and privacy and security compliance. During her career, Sonya has served as Corporate Compliance Officer for several organizations and led wide-ranging audits to ensure compliance with regulatory requirements and internal processes.
The Burchfield Group Comments on 2018 Formulary Exclusions
CVS Health (CVS) and Express Scripts (ESI) have publicly released updates to their 2018 formulary exclusion lists. Both have stated that member disruption was a key consideration when expanding the exclusion list, and estimate that over 99% of members will not be affected by the 2018 formulary exclusions. Both CVS and ESI have claimed these exclusions will result in plan cost savings over previous years.
What does this mean for you if CVS or ESI administer your prescription drug benefit?Member disruption caused by changes in formulary exclusions should be lower than in previous years.
Neither CVS nor ESI made significant restrictions on their specialty offerings, which continues to be largest driver of increasing costs. Both plan to review Hepatitis C and Autoimmune (e.g. Rheumatoid Arthritis, Psoriasis) classes, with CVS announcing their intention to announce recommendations in the fall.
Both plans have chosen to favor epinephrine products from Mylan (EpiPen brand and authorized generics) and exclude Kaleo’s Auvi-Q.
CVS introduced their Transform Value program as an entry into outcomes-based management for oncology, obesity and respiratory, and plan to share additional details later this fall.
ESI closed the gap on CVS’ exclusions by adding numerous multi-source brand exclusions, eliminating brand products from the formulary that have FDA approved generics. ESI’s list has expanded to exclude 159 products, slightly more than that of CVS.
ESI removed the osteoporosis drug Forteo (parathyroid hormone recombinant, Lilly) in favor of Tymlos and bisphosphonates (i.e. alendronate) for treatment. Tymlos is a synthetic form of parathyroid hormone that has the same mechanism of action as Forteo, produced by Radius, a smaller pharmaceutical firm.
The number of exclusions on CVS’ list remained relatively consistent, as they removed 17 products from the list but added back the same amount. Among the changes are the exclusion of noted SGLT-2 inhibitor for diabetes, Jardiance, and the addition of Invokana (Farxiga was still on formulary). CVS also added back oncology and MS drugs that it had previously excluded.
The generic savings of Viagra launch at end of 2017 may be blunted by CVS providing another brand product in Levitra to select from.
For more insight on what these formulary exclusions mean to you, contact your Burchfield consultants at 800-778-1359 or go to http://www.burchfieldgroup.com/contact-us/ .
The Burchfield Group to participate in the HCCA Managed Care Compliance Conference
Derek Frye, Audit & Compliance Practice Leader, will be presenting at the upcoming Health Care Compliance Association (HCCA) Managed Care Compliance Conference along with Sonya Henderson, Senior Vice President of Corporate Compliance & Government Programs at FirstCare Health Plans. They will be presenting "Deep Dive on DIR: CMS’ 2017 Focus on Enforcement for One-Third Financial Audits and Your Rebates". The event will take place in Scottsdale, AZ on January 29-February 1, 2017. For more information, go to http://www.hcca-info.org/Portals/0/PDFs/Events/Brochures/hcca-2017-managed-care-brochure.pdf.
The Burchfield Group is a sponsor of the 2017 Health Action Council (HAC) health and wellness benefit conference in Ohio
Look for our representatives at the upcoming HAC conferences in Columbus, Ohio in January and Cleveland in February. Staff will be available to meet before and after the event to discuss upcoming industry changes, share insights on the latest pharmacy trends, and discuss your needs in the changing health care landscape. To set up a personal meeting contact Phil DeNucci at [email protected] or at 651-389-5664.
CMS Industry-wide Timeliness Monitoring Starts Now
Recently, CMS announced a deadline for Industry-wide Appeals Timeliness Monitoring. Once you receive notice from an audit contractor, you only have 15 days to produce the required 7 ODAG universes and 10 CDAG universes, and these universes must be accurate and meet the 2016 program audit protocol requirements. Health Plans, are you ready? The Burchfield Group has experts that can help you validate the data formatting and verify that you have everything covered. Contact us for more information.
The Burchfield Group welcomes Kristin Gray to its team
Kristin Gray joins The Burchfield Group as a Strategic Consultant for the health plan market. As a strategic consultant, Kristin advises clients on how to most effectively manage their pharmacy benefit programs. Kristin brings 20 years of experience in a variety of healthcare settings, including specialty pharmaceuticals, strategies in GPO contracting and managed markets, and practice management to the Burchfield team. Her experience gives her deep insight into the pharmaceutical marketplace at the manufacturer, wholesale, and retail/physician provider levels. Kristin also brings a depth of experience in specialty pharmaceuticals life cycle management, self-injectables, generics and biosimilars.