PBNJCode Provides Cost & Channel Management for J-Codes & Specialty Medications
About Us
PBNJCodeFounded in 2023, PBNJ (Pharmacy Benefits Negotiates J-Codes) is an advocacy company that is designed to save employer groups money on their medical J-Code spend. PBNJ’s specialty drug analysis employs proprietary benchmarks and algorithms to identify inefficiencies by comparing medications paid for and delivered in the medical benefit to the medication paid for and delivered in the pharmacy benefit. Performed in conjunction with a cross-disciplinary mix, clinical overview and financial analysis, the results of the specialty drug analysis enable us to provide recommendations and potentially facilitate a long-term solution for managing Specialty medications.
Coordinating care between the member, physician & dispensing facility is essential part of the PBNJ approach. There are three unique cost saving silos:
Medical Benefit
Pharmacy Benefit
Bolt on
International sourcing
Manufacturer assistance programs
Our Solution
Solution-
The Problem
High-cost prescription drugs have been punishing pharmacy plan budgets for years. However, did you know that drugs prices also affect medical plan costs?
Prescription drugs are billed in either the medical plan or pharmacy plan. Medications that the patient cannot administer are billed through the health plan using J Codes.
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The Cost of J Code drugs
The billed / paid charges for J Code drugs are substantially more expensive than the same medication billed thru the pharmacy plan. There are many factors contributing to this such as regulation, markup and facility cost, to name a few.
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The Solution - Transparency
By evaluating J Codes both retrospectively and in real time, we can provide the benchmarking and price transparency necessary to manage J Code claims. Let the data drive the solution. We have been capturing 20% average saving on claims that we target.
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Patient Experience
Utilizing clinical outreach, we balance claims savings and low patient disruption. The “care triad” consisting of patient, physician & injection sight are engaged to provide the best clinical and financial outcomes.
Case Study - California Claim (Ocrevus)
CASE STUDYAudit Objective & Methodology
- Medical/Rx claims overlap and duplication of payment
- Financial understanding of the various delivery silos
- Correct policies/procedures for benefit coverage
- Optimization of Specialty Spend and Management by site of care
Medical Data Analysis
“J-Codes” are part of the Healthcare Common Procedure Coding System (HCPCS) Level II set of procedure codes. J-Codes are used by Medicare and other managed care organizations to identify Specialty injectable drugs and oral immunosuppressive medications.
Pharmacy Data Analysis
PBNJ’s specialty drug analysis employs proprietary benchmarks and algorithms to identify potential waste and inefficiencies by comparing medications paid for and delivered in the medical benefit to the medication paid for and delivered in the pharmacy benefit. Performed in conjunction with a cross-disciplinary mix, clinical overview and financial analysis, the results of the specialty drug analysis enable us to provide recommendations and potentially facilitate a long-term solution for managing Specialty medications.
Results
Ocrevus- is administered by intravenous infusion as a 600 mg dose every 24 weeks.
| Patient Name | Date of Serivce | Medication Name | Number of Units | Medical Facility Cost | PBM Cost | Savings |
|---|---|---|---|---|---|---|
| XXXX XXXX | 6/11/20XX | Ocrevus | 300 | $78,677.00 | $17,162.50 | $61,514.50 |
| XXXX XXXX | 6/25/20XX | Ocrevus | 300 | $77,867.00 | $17,162.50 | $60,704.50 |
| XXXX XXXX | 1/7/20XX | Ocrevus | 600 | $165,680.42 | $34,322.50 | $131,357.92 |
| XXXX XXXX | 4/26/20XX | Ocrevus | 600 | $224,206.89 | $34,322.50 | $189,884.39 |
| SAVINGS | $443,461.31 | |||||
Specific claim data showing lowest net cost for PBM, International Pharmacy & MAP/PAP programs.
