Third Party Billing Derek Robertson Consultant The Hemophilia Alliance

1
Third Party BillingDerek Robertson Consultant
The Hemophilia Alliance

• 12th Annual 340B Coalition ConferenceWashington,
  D.C. July 15, 2008

2
The Issues Public Payers

• Medicare Part D Contracting
• Medicaid Billing at acquisition or
  carve-out Dispensing Fee Specialty
  Pharmacy Carve outs Medicaid Managed Care

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The Issues Private Payers

• Private Insurers consolidating companies
• Contracting with PBMs
• Forming their own PBMs and specialty pharmacies
• Signing national contracts

4
What are Specialty Pharmaceuticals?

• Drugs which are used to treat conditions which
  require a high level of specialized care usually
  over a prolonged period of time
• Drugs are characterized by high cost and in many
  instances are biologicals with complex
  manufacturing processes
• Clotting factor fits perfectly

5
Growth of Specialty Pharmacy

• In 2006 specialty pharmacy drug spend was 54
  million or 20 of overall drug spend
• By 2010 it will increase to 99 million
• Source Specialty Pharmacy News, July, 2007.
  Atlantic Information Services

6
Why is This Happening?

• PBM acquisitions of Specialty Pharmacies
• New PBM contracts with Managed Care
• Increased drug utilization
• New software tracking Specialty Pharmacy drugs
  previously managed under medical benefit

7
A Note on Employers

• Large employers find their own insurance plans
  and third party administrators
• Perhaps a bigger challenge than payers
• How do we reach the powers that be at large
  employers like GM and BOA?
• Will they change plans for 1or 2 EEs?
• Employer can overrule payer when the plan is self
  funded

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What Can We Do?

• Be proactive. We need to talk with payers
• It is not enough to say, dont sign a national
  contract. We must explain alternatives such as
  the benefit of the 340B Program
• Dont approach payer as an adversary but as a
  potential ally who needs education and information

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Contact Information

• Derek Robertson
• Tel [phone]
• Email derekrobertson_at_verizon.net