Laura Bobolts, PharmD, BCOP

Prior authorization has a negative connotation and justifiably so. The way the U.S. government was founded on checks and balances, prior authorizations offer this to keep the payor's best interest in mind and create some aligned accountability. It is, in theory, a tool for checks and balances to determine medical necessity. In reality, it is a means to deny care in fully-insured models and to divert care (on the rx side) to the most rebate and GPO fee friendly drugs. Even prior authorizations done by transparent PBMs still have the risk to frustrate providers and worsen patient outcomes. What are the chances a patient's care is significantly delayed until their next visit or abandons any treatment whatsoever? They are two dimensional, determining if the patient qualifies for the drug (typically fitting characteristics of those enrolled in the clinical trials) and offering an approved or denied stamp. Even if approved, there might be more cost-effective options that achieve the same outcome. If denied, what clinical individuals are working with the provider to find alternative solutions? Is anyone trying to deescalate therapy when possible or should we just reauthorize drugs without a second look? We've got to do better. #apothicorwellness #pharmacists #priorauthorization

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Happy Friday! 🌞 Another summer*, another year serving our communities through the power of #pharmacy. This profession isn't always easy, but it's incredibly rewarding. Why? Because we get to help people every single day. 🙌 I don't sugarcoat it though. The challenges are real: -Pandemic pressures -PBM struggles (Check out this video to learn more: https://lnkd.in/etqpyFXR) -An overly complex healthcare system -Burnout -Shrinkflation -Pharmacy school curriculum not changing fast enough... ...are all strangling the profession. But we're fighters. We're innovators. That's why I'm proud to be part of the Mark Cuban Cost Plus Drug Company, PBC, where we're working to make medications affordable for everyone. To my fellow pharmacists: Keep fighting the good fight! Together, we can make a real difference. 💪 (*Most pharmacists were licensed in the summer after pharmacy school.)

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New York Focuses on PBM Transactions!!! New York State Regulators Set New Rules To Rein In PBMs’ Behavior Bloomberg (11/20, Tozzi, Subscription Publication) reports, “New York state regulators are setting new rules to rein in the behavior of prescription drug middlemen – including units of CVS Health Corp., Cigna Group and UnitedHealth Group Inc. – in a step the state’s top financial regulator said will boost competition and transparency.” Regulations that are “taking effect this month will make pharmacy benefit managers, or PBMs, publish their lists of covered drugs and directories of pharmacies in their networks.” New York “will also bar PBMs from steering patients to their affiliated pharmacies and allow local pharmacies to offer mail-order and home delivery.” #pbm #payers #healthcare

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📍 How to work with us at Mark Cuban Cost Plus Drug Company, PBC: 💊 1. If you're a pharmacist, clinic, or hospital looking for other B2B options to buy low cost prescription drugs for your patients, consider shopping the Cost Plus Drugs Marketplace: https://lnkd.in/gypvkXde 🏡 2. If you're a patient but love your local pharmacy and want to keep your prescriptions closer to home - great! Check out www.teamcubancard.com to see if we stock your drugs and/or have your pharmacy included in our pharmacy network today. 👩‍🦰 3. If you're a patient in need of a lower cost or another option for a mail order pharmacy and pay cash - check out: www.costplusdrugs.com. 👩🏿‍⚕️ 4. If you're a prescriber and your patient wants their meds sent to cpd.com, check out this page: https://lnkd.in/gsyQU7hJ. 🛜 5. If you're a retail pharmacist PIC or pharmacy owner and want to join our retail pharmacy network - welcome! Fill out the form at: https://lnkd.in/gnruGTkH. 🏥 6. If you're a hospital and want to know more about our 503B facility and buying a product we manufacture on the FDA shortages list, LMK and I can connect you. 💵 7. If you're a payer and want to connect with us, complete the form at this page: https://lnkd.in/gcnq33kF. ❓ 8. If you have a general query that does not fit any of these categories, you can email us at: [email protected]. 🧑🏼‍🔧 9. If you're looking for a hashtag #job with MCCPDC, check out our jobs page right here at LinkedIn! https://lnkd.in/gegjQBq3 (Please note that we do not currently work with recruiters at this time.)

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Had a really great time joining Justin Cole on the DISRxUPT podcast with Cedarville University last month! Would highly recommend the podcast for those with an entrepreneurial spirit who work in pharmacy, and if you are interested in learning more about us Pharmless Health P.S. We started the holiday giving season early! Download our FREE E-book on healthy living by clicking the link in my bio section ☝️ #PharmlessHealth #DISRxUPTPodcast #HealthandWellness

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Regeneron is facing a critical strategic decision: Should they persist with the failed #strategy of cannibalizing Eylea 2mg sales with Eylea HD, or should they focus on protecting their $4.5B market share in Eylea 2mg from the onslaught of biosimilars by deploying aggressive incentive programs? In their recent conference call, Regeneron highlighted “stickiness” as a defense for retaining the Eylea 2mg market share—referring to the combination of brand loyalty and switching costs. However, as Ben Franklin wisely said, “To persuade, appeal to incentives, not reason.” For Regeneron, “stickiness” alone is unlikely to outweigh the power of incentives. So, will Regeneron choose to defend Eylea 2mg with incentives, or will they continue with their current strategy, risking significant market share loss? I’m not optimistic. As Charlie Munger aptly put it, “The inconsistency avoidance bias is a strong driver of human decision-making.” #retina #pharmaceuticals #ophthalmology

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Make no mistake: 💊 we are just getting started on our Cost Plus Drugs Pharmacy Affiliate Network! Just yesterday we increased our baseline dispensing fee to $12/claim for pharmacies that team up with us. On 10/1, we have hundreds of new pharmacies coming to the network joining thousands already in network now that we have higher dispensing fees too! We also have unfunded AND funded lines…and the funded experiment with our own employees, “Project Alpo” is getting ready to grow again as well. Now is the best time ever to team up with us, and create a win-win here. We are excited to grow, and hope you’ll be joining us!!! Form link to learn more is on my profile page, PICs and pharmacy owners. 💊 If you’re a patient, check us out. We might be able to save you some $ and keep your local in network pharmacy too. #TeamCubanCard www.teamcubancard.com Mark Cuban Cost Plus Drug Company, PBC #pharmacy #localpharmacy

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A recent opinion piece in The Hill by Paul Alexander discusses the complex relationship between high drug prices and PBM rebates, shedding light on how these rebates can distort the market and negatively impact patients. While PBMs claim to negotiate lower drug prices, Pitts notes that the rebate system they manipulate often leads to higher list prices and increased out-of-pocket costs for patients. "Rebates create a perverse incentive for manufacturers to set higher list prices, knowing they must offer substantial rebates to secure formulary placement," Alexander explains. This issue is particularly relevant for independent #communityoncology practices, as the distorted market can affect drug availability and affordability for patients with cancer. The article calls for greater transparency and reform in the #PBM rebate system to ensure that savings are passed on to patients rather than benefiting intermediaries. Read the full article: https://lnkd.in/ene8XUaa

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Sooner than You Think: When Will the #340B Program Be the Largest #Drug Program in the Country? The IQVIA 340B report is chock full of great info on what is happening in 340B. But, with some other data, it points to how fast 340B will be the largest drug program in the country—bigger, even, than #Medicare #PartD. Main Takeaways: The report tells us that: • In 2023, 340B sales were $124.1B. • 2022 to 2023 growth was an astonishing 16.5%. • 5 year growth was a more astonishing 129.4%. • Those growth rates were (can we be more astonished?) more than 3x the growth rate of non-340B sales. • #Hospitals and #clinics increased 18.9% year-over-year and retail and mail channels was up 10.2%, “despite ongoing #contractpharmacy restriction[s]”. • The average 340B discount was 55%. • 2023 340B profits/subsidies were $56.1B. But Where Are We Headed?: Good question. I applied the current growth rate of 16.5% to the current 340B sales of $124B and compared that result to Part D gross spend by the government in 2021, marked up by the average growth rate for Part D from 2016-2021. Based on the current rate of increase in the 340B program, the 340B program--already the second largest drug program in the country--will be the largest program, eclipsing even Part D, in just 6 years. At that point, 340B sales will be in excess of $310B a year. Applying the current relationship between 340B sales and 340B profits/subsidies ($124.1B to $56.1B), that would mean that, in 6 years, 340B profits/subsidies would be in excess of $145B. In any program that even approaches that size, patients should receive drugs without any #costsharing where their income is less than 300% of the federal #poverty limit, all patients should have cost-sharing determined based on net (not inflated) gross prices, and 340B hospitals should have a set obligation to provide a designated percentage of revenue to charity care, without fail. It is unconscionable that federal reform proposals and state contract pharmacy laws fail to include these basic patient protection provisions. The 340B program must put the #patientfirst, beginning with that patient at the #pharmacy counter, whether they seek #medication for a #chronicdisease or a #raredisease. It’s the right thing to do, and we should do it now. #managedcare #charitycare 3charities #financialneed #allcopayscount #copays #costsharing #fpl #access #affordability #rarediseases #lifesciences

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On Friday we learned Baxter is considering the sale of its kidney care business to private equity firm Carlyle Group for more than $4 billion. Baxter announced plans in early 2023 to spin off its kidney care and acute therapies businesses into a separate, publicly traded company called Vantive. In March, the company said it was also considering selling the segment to private equity. A deal could be announced “in the coming weeks.” On their latest earnings call in May, CEO Joe Almeida said the company is still "pursuing dual pathways" with a spinoff or planned sale. A few data points from my Vantive preview earlier this year: 𝐆𝐫𝐨𝐰𝐭𝐡 𝐓𝐫𝐞𝐧𝐝𝐬 𝐃𝐫𝐢𝐯𝐞𝐧 𝐁𝐲: • 3-4% expected market growth through FY26 • 🏠 ongoing shift to home • ⬆ awareness of blood purification tx • ⬆ incr. patient volume + complexity • 🌐 focus on connected devices 𝐍𝐞𝐚𝐫 𝐓𝐞𝐫𝐦 𝐏𝐢𝐩𝐞𝐥𝐢𝐧𝐞: • Sharesource Analytics (PD) • Sharesource Adequest (PD) • Patient Monitoring Suite • Sepsis Diagnostic • PMX Sepsis Filter • China CRRT Fluids 𝐅𝐮𝐭𝐮𝐫𝐞 𝐏𝐢𝐩𝐞𝐥𝐢𝐧𝐞: • Home PD Solution Generation • Artificial Kidney Technology • PrisMax 3 (CRRT) • US Citrate & Calcium Solutions *** If you're following or building in this space, I'd love to hear what's on your mind and what you're excited to see in kidney R&D in the coming years. -- Sources: [1] https://lnkd.in/epzEZEPj [2] https://lnkd.in/epzEZEPj [3] https://lnkd.in/eQZVveu2 [4] https://lnkd.in/etivEawH

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While GLP-1 use for Obesity is growing much faster than it is for T2D, these patients are even more likely to stop using the drugs early. One study published in JAMA Network Open showed that by 12 months, it was a coin-flip as to whether someone who started taking a GLP-1 for Obesity would still be taking it. This data is from 2021. I'd hypothesize that those who were adopting GLP-1s for weight loss that early were the ones who were most aggressively seeking help. This data may actually look worse over time. Is it because the drug is failing these patients, or because the patients aren't taking the drugs with the appropriate support? If we are going to invest this much money in a medication to address a serious disease (obesity), we need to solve this.

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In the PBM landscape, pricing often appears similar across the board. However, the real value differentiator lies in how PBMs manage clinical programs. Effective clinical management not only drives cost savings but also ensures optimal patient outcomes. It’s essential to look beyond pricing and focus on the quality of clinical programs when evaluating PBMs. 💊💡 #PBM #TransparentRx #ClinicalManagement #PatientOutcomes #PharmacyBenefits

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GLP-1 medications, such as semaglutide and liraglutide, have been transformative for many patients managing conditions like diabetes and obesity, but for independent pharmacies, they can be a financial nightmare. The high upfront costs to stock these drugs, combined with the low reimbursement rates set by Pharmacy Benefit Managers (PBMs), have created a significant strain on community pharmacy owners, many of whom operate on already slim margins. The situation is exacerbated by PBMs, which often negotiate reimbursements that don't even cover the cost of the drug, let alone the dispensing fees. Despite these challenges, independent pharmacies should still strive to offer GLP-1s because they play a vital role in patient care, offering personalized counseling and fostering strong relationships with patients who rely on these medications. By continuing to offer these drugs, pharmacies can maintain their competitive edge, meet patient demand, and position themselves as essential healthcare providers. Advocacy efforts, such as pushing for fairer reimbursement practices and greater transparency from PBMs, as well as forming cooperative purchasing groups, can help mitigate some of the financial burdens. Independent pharmacies should not let PBM-driven challenges deter them, as their ability to serve patients with high-quality, personalized care is one of the key factors that differentiate them from larger corporate pharmacies.

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At DisclosedRx, this isn't just a statement—it's our core commitment. But what does fiduciary responsibility really mean in the world of Pharmacy Benefit Management? It means every decision we make, every recommendation we offer, and every action we take is driven by one primary goal: benefiting our clients. This contractual and ethical obligation sets us apart in an industry where such commitments are rare. Why do so few PBMs embrace fiduciary status? Curious to learn more about how our fiduciary approach can benefit your organization? Message us directly or visit our website to discover the DisclosedRx difference: https://disclosedrx.com/ #FiduciaryPBM #ClientFirst #PharmacyBenefits #HealthcareCosts #DisclosedRx

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🔍 Prior Authorization Process in Cardiology 🩺 Specializing in cardiology, doctors perform various procedures that require prior authorization to ensure optimal patient care and compliance with insurance policies. 💡 Understanding the Prior Authorization Process: - Cardiologists often request prior authorizations for procedures like cardiac catheterizations, stent placements, or pacemaker insertions. - Insurance companies may require detailed documentation, including patient history, test results, and justification for the procedure. 📊 Case Study: Dr. Smith, a cardiologist, requested prior authorization for a coronary angiogram for a patient with chest pain. By providing thorough documentation, the authorization was approved promptly, allowing for timely treatment. 🔑 Key Points: - Prior authorizations in cardiology aim to streamline the process and prevent delays in crucial cardiac interventions. - Collaboration between cardiologists, insurance companies, and prior authorization specialists is essential for a smooth workflow. 🔗 #Cardiology #PriorAuthorization #Healthcare Ending Message: If you are looking for Prior Authorization Outsourcing Services, please connect with me via email at [email protected] or by scheduling a Meeting at https://lnkd.in/e4nbe7jV

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