About Anthony Masotto, Vice President of Pharmacy Solutions, Drexi
Anthony Masotto is vice president of pharmacy solutions for Drexi. Anthony brings more than a decade of group pharmacy and stop loss insurance experience to his role at AMPS. After retiring from professional hockey with the Ottawa Senators organization in 2006, Anthony started his insurance career in 2007 with Assurant Employee Benefits, followed by Sunlife Financial, Remedy Analytics, and ELMCRx. Through his vast knowledge and expertise within the pharmacy space he has become an industry leader in contracting, formulary management and cost containments strategies. He is a member of the Self-Insurance Institute of America, and the Society of Professional Benefit Administrators. Anthony graduated from Colgate University with a bachelor’s degree in political science while playing D-1 hockey. He now resides in San Diego, CA with his wife Viktoria, twin boys Oliver and Charlie, and daughter Alexandra.
About Drexi
Drexi empowers you with a curated approach to a better you that goes well beyond savings. Our intentions can be summed up simply. We believe that everyone has the right to honest pricing on their prescriptions. We are dedicated to making your prescription medications affordable, manageable and cost-effective. People choose us because we give them options. Drexi members get our cost on prescriptions through a premier network of pharmacies. No hedge or gamesmanship—just fair, honest pricing. There are other benefits too, of course, like saving more money than other PBMs. But what makes us really stand out is that we are wellness advocates, and we are a fiduciary PBM. When our members are healthy, they are happy, and there’s nothing more valuable than that. The fact is that the prescription drug sector is one of the opaquest industries in the world, which means they are able to get away with a lot. Drexi is changing all of that by empowering its members and plan sponsors through honesty and integrity—a trait that has been lacking in this industry for far too long.
Medical Travel & Digital Health News (MTDHN): Tell us about your focus at Drexi in relation to Advanced Medical Pricing Solutions (AMPS).
Anthony Masotto (AM): Drexi, at its core is a PBM without conflicts that offers fair and honest pricing, but we will get into that later. Drexi started 9 years ago as a Simple SaveRx doing complex claims adjudication for new go-to market drugs as well as MSP and PAP programs for some of the biggest pharmaceutical manufacturers in the world. However, David Kwasny, our co-founder, wanted to change the PBM industry and the only way to change the PBM industry was to become PBM.
Drexi is like no other PBM as we are a full-service fiduciary PBM, built from the ground up. We adjudicate our own claims, and we own our own contracts, therefore, we control costs from the start. You hear a lot in the market today about transparency and passthrough. For this to be true you can’t rely on broken contracts, other PBMS dictating which pricing is negotiated, or what drugs are preferred. Most of the 70+ PBM’s in the market today lay on top of the big 3 (CVS/Caremark/ESI/Optum) and all this is doing is adding another layer of cost to an already broken system.
Drexi as I mentioned is a PBM without conflicts: We don’t own any product. We don’t dispense any product. We don’t prefer any product. Because of these, we are able to be agnostic to the member and the plan with therapeutic options and price. With Drexi as a fiduciary PBM, I have no financial incentive to dispense one drug over another. We simply want to do what is in the best interest of the member and Plan financially, while ensuring the best clinical outcome to the member.
Second differentiator: We create competition between pharmacies. Again, we don’t own any pharmacies or products, and we don’t dispense products. This means we have no conflicts of interest. We’re just focused on finding the lowest cost medications.
We partner with seven or eight different specialty pharmacies. Once we deem them to be clinically appropriate, we allow them to bid on filling claims. This is how we create competition between both retail, mail and specialty pharmacies.
Last piece to the puzzle is our member facing tools and applications that allow members to shop themselves and see where the best place to buy their medications are. There can be huge price swings from pharmacy to pharmacy and if we can continue to educate and give members these tools it allows us to that information based on market drug costs and bring it to the big box stores to share that information. The tools also allow members to have more in depth conversations about their medications. The member portal not only gives them information about their plan design and cost, but also gives them affordable alternatives and therapies to where they acquire their medications.
MTDHN: Tell us about high-cost specialty drugs. How does your approach differ from the traditional approach?
AM: When it comes to specialty medication, you’re talking about 2% of the claims in a particular group that consumes 50% of the spend. Because specialty diseases impact fewer people, it’s important to carefully manage specialty drugs. This ensures members are receiving effective medications they truly need.
This is where the big PBMs are making an enormous amount of money from rebates. It’s in their best interest to push those particular medications.
Through our pre-authorization process, clinical programs, and high-cost claim edits, we’re able to put a pause on these high-cost specialty claims. We want to review them, and make sure all the boxes have been checked before approving it within that therapeutic class.
Once we deem clinical appropriateness we ask: What is the best way to source this drug? Is there a payer system available? We look into things like MSP, PAP, Copay Cards, and international options.
Canada and England, for example, don’t have rebates or any of the overarching expenses, so you can get those drugs at 50-60% less than in the United States.
MTDHN: What about the ethics?
AM: They’re exactly the same. Same manufacturer. Same drugs. Same box and all in English. It’s just coming from Canada instead of a specialty pharmacy somewhere in U.S. Most, if not all, of these medications aren’t even manufactured in the U.S., which most people don’t realize.
MTDHN: What do you think about the entry of all these high-cost gene and cell therapies? How do you approach that?
AM: What’s important around gene therapy is making sure the test is being done. I’ll give you an example: Zolgensma is a $2.2 million high-cost medication drug. It’s a one-time shot for children with muscular atrophy and it saves lives. However, it only works for a tiny percentage, depending on genetic makeup, the patient’s specific disease, and other factors.
You need to make sure all the appropriate steps have been taken and all options have been exhausted before you allow a drug like this to be administered and is imperative – as this is a one and done drug. We don’t want to deny those medications, but we also don’t want to approve them just because an individual has that disease.
Our process ensures the highest possibility and clinical appropriateness that this drug could be effective for an individual. There is no guarantee when it comes to gene therapy drugs, but you want to give both the member and the plan the best chance that it will.
MTDHN: Do you have a medical board that looks at all of this?
AM: Yes, we do. What’s nice about making money only from a per employee per month (PEPM) fee is that it allows us to be agnostic and to bring the best clinical expertise in as a partner.
We don’t make any more money on a specialty drug, for example, than we do on a generic drug. It’s all the same for us. We only get paid based on the work we do and that payment is on a PEPM basis.
MTDHN: Tell me about your client mix.
AM: We now have health plans with tens of thousands of members. We do carve out infusion medication management, which has grown from about 500 employees to almost 2,000. For the most part, we serve the under 50,000-employee market.
MTDHN: How does site of care impact the cost of administering these drugs?
AM: It has an enormous impact if you think about infusion medications, hospital outpatient infusion, and the cost associated with those drugs. If I have rheumatoid arthritis and am getting my infusion in the hospital, that could cost my plan $40,000. Drexi can outsource that to a private clinic at a much lower price.
When we start talking about infusion management, we pull that apart to get down to unit cost of that medication, ensuring the Plan isn’t being overcharged or missing out on a less expensive or equally effective alternative to infusion therapy.
MTDHN: What do you think about reference-based pricing for drugs?
AM: We’ve explored that, and I think it’s a great idea. We’ve looked at it a couple of different ways, but do you get a dollar amount per therapeutic class? It would cover a specific drug, but if an individual wants to go above and beyond that, is it on their dime?
The real issue is employers must deal with member disruption. They say, “Hey, you’re only going to cover $500 on this therapeutic class for this medication, but my doctor says he wants me to be on this drug.”
How do you handle those situations? We must be mindful of the different risk tolerances for different groups. It must be the right solution at the right time.
MTDHN: What is the role of digital solutions in supporting your platforms?
AM: Digital is important because members don’t want to go through all the processes to search for their drugs. Anything Drexi can do from a technology platform to make that process easier, automatically drives savings down.
It’s a one-touch solution that tells the member they can find the same drug at a cheaper location. They click yes. We take it from there, go to the prescriber and make those drug changes. We ship it over to the selected location and they pick it up. Technology is creating ease of acceptance and enabling members to take advantage of potential savings.
MTDHN: Are you aware of medical travel for medications in countries like, for example, Mexico and Costa Rica?
AM: It goes back to the international sourcing aspect. One of the biggest medical travel areas is around insulin. People in the Northern states will go across the border to Canada to buy their insulin. This can be solved with education. I don’t think people would be doing this as often if they knew we could get them a bottle of non-branded insulin for under 30 dollars. When I say non-branded, that means a different label sticker, but the same manufacturer and manufacturer line. Most times through payer assistance, Drexi can get the drug covered for free. This is why members are frustrated. These programs exist today to do what’s in the best interest of the member, not the non-fiduciary PBM. For a non-fiduciary PBM, their goal and the only way they make money, is to sell you more drugs at a higher cost.
Instead of them traveling to Canada, we simply leave a formulary open that gives them the option to buy the non-branded, lowest cost insulin, and ship it to them (much like if they went through one of our mail-order partners).
I can purchase Humira, for instance, from Canada for 50-60% less than stateside. We have an 85% success rate in doing this. With that kind of cost savings, we can waive the member’s deductible. It is about doing what’s best for the member and for the plan.
MTDHN: Going forward, what do you envision for regulatory issues such as rebates down the road?
AM: You already see PBMs setting up group purchasing organizations (GPOs) and overseas entities. Rebates will be called something else, like an administration fee. They know how to keep one step ahead of regulatory issues.
Optum Express and CVS have grown by double digits every single year for the last 15 years. From a lawmaker perspective, how do you combat that? At the end of the day, I think they will be regulated but this won’t change their profitability. It will just get passed on to the consumer. PBMs are some of the smartest people you will ever meet, and they are 5 steps ahead of any regulation that may happen.
We know there’s a better solution. The question is, with the amount of money flowing through the drug industry, who is willing to step up and say its ok to make money? Drexi is trying to change this narrative one prescription at a time and we are well on our way to being a market leader in the PBM space.