Some good news has finally been announced for one high priced insulin product. Semglee (manufactured by Biocon Biologic and Mylan) is a new long-acting insulin product that was recently approved by the FDA in June. Semglee is similar to Lantus (manufactured by Sanofi-Aventis) which is a highly prescribed insulin product. Semglee has been released with an average wholesale price (AWP) of around 65% less than Lantus.
Semglee vs Lantus AWP Comparison
Currently, a prescriber would have to write the prescription for Semglee instead of Lantus, but based on a recent drug trial, Semglee has shown the same safety and efficacy when alternating between Lantus and Semglee, which likely will lead to an FDA approved interchangeability status. This would allow Semglee to be substituted for a prescription written for Lantus. An employer with around 6 utilizing members could see savings of more than $20,000 per year, as a result of this FDA approval.
When considering a PBM, self-funded groups should be aware that PBMs are unregulated, and transparency claims are entirely at the discretion or invention of their sales strategy.
With the spotlight focused on high drug prices and the role PBMs play, it is easy to understand the appeal of the pass-through model where the PBM will transfer their network discounts, rebates, and general PBM services for one simple administrative fee, typically calculated as Per Member Per Month (PMPM).
When contracts are passed-thru multiple PBMs and pharmacy benefit resellers, there are hidden revenue streams cut from the spread of each network claim, percentage taken from rebates, and formulary management fees. Potential savings diminish when processed through this funnel.
Retail networks are pre-negotiated and subject to variable and potentially less aggressive discounts at smaller or more poorly negotiated pharmacies. Your PBM may not reliably deliver on promised savings when network discounts are “passed-thru” as they are, with no adjustments.
APC believes a pharmacy benefit plan will achieve goals of optimal savings when they negotiate for a guaranteed AWP discount across the entire network. When a PBM is obligated to deliver on their negotiated AWP discounts, they assume more risk, which subsequently compels them to renegotiate low-performing network contracts actively.
APC breaks you out of the world of restrictive canned PBM contracts. We believe all payers, no matter the size, deserve PBMs who fight for their business. APC works with a network of mid-market PBMs who remain accountable to their guarantees. Our PBM expertise can help craft a contract and plan design that delivers the best savings and outcomes. We offer an alternative to the smoke, mirrors, and the long, costly RFP process to help the payor efficiently underwrite their policy and provide budgeting forecasts. After the contract is signed, APC stays to provide PBM management to ensure the PBM delivers on promised savings.
To a mid-sized health plan, $5 million in Rx spend may seem like a lot. However, to a Big 3 PBM, managing 80% of all prescription drug claims, it can be a drop in a bucket.
Now imagine you manage a plan, spending less than $1 million? Lost in the crowd, these smaller groups are often missing out on savings and flexibility.
APC has over 15 years of experience in PBM procurement and management. As small group advocates, we understand the unique needs and challenges of managing a self-funded healthcare plan. We actively curate a vetted PBM marketplace and can work with your organization and Benefits Consultant to provide efficient PBM acquisition, implementation support, and ongoing monitoring and reporting. An innovative and competitive marketplace of mid-market PBMs offers competitive rates, flexible contract terms, ongoing monitoring and reporting, and implementation support.