Many of us have had to deal with insurance companies that refuse to cover a certain medication that our doctor told us we needed. Even though you may have prescription drug coverage through your insurance, the insurance company will try to regulate the dosage, brand, or even amount of medication they will cover, regardless of what the doctor orders. however, it may not all be the fault of the insurance companies. What regulates much of drug costs today are companies called Pharmacy Benefit Managers, or PBMs. caremark, express scripts and optum rx are the three most important pbms. They administer prescription drug benefits on behalf of health insurers, Medicare Part D drug plans, large employers, state Medicaid programs, and others. its function is explained in truveris. com, describing themselves as “pharmacy experts with the analysis and insights to bring objective truth, knowledge and understanding to pharmacy.” describe pbms this way, “pbms operates in the middle of the prescription drug distribution chain. They develop and maintain lists, or formularies, of covered drugs on behalf of health insurers, which influence which drugs people use and determine which drugs are out of service. out-of-pocket expenses”.
the original goal of the pbms was to reduce drug costs by negotiating with drug manufacturers. however, pbms reportedly negotiates with drug companies to determine what level of reimbursement the drug company will offer directly to pbm for certain drugs to be placed on a “preferred list.” this process appears to lack input from medical professionals regarding which medications may be the best option for treatment and therefore should be “preferred.” Refunds are paid directly to PBM. depending on the contract, pbm will pass all, part, or none of the reimbursement to the employer or plan sponsor.” so they don’t have to waive any of the rebates they receive, or make the terms public. savings don’t always roll over to the patient or the local pharmacy, yet the pbm generates billions of dollars in profits, while health care and prescription drug costs continue to skyrocket.
some stewart county residents have been receiving letters from their insurance company telling them they can’t use their local pharmacy, pushing them into a chain, like cvs, with locations closer to stewart co. be in paris, tn, or murray, ky. one such letter, dated Sept. On January 18, 2020, the rule obtained a copy of, states, “Preferred Retail Pharmacies in 2021 include CVS Caremark, you may choose to choose a Preferred Retail Pharmacy in the network.” it listed, walgreens and kroger pharmacies. obviously none of which are located in stewart co. the letter mentions local pharmacies, stating that they will no longer be a preferred pharmacy as of 2021 and will now be considered a standard cost-sharing pharmacy. the letter went on to tell the customer, of course he can continue to use but he can’t take advantage of the lower cost sharing he can at ‘in-network’ chain pharmacies. other letters indicate that you will be responsible for all costs (pbm will pay nothing) if you do not frequent certain chain stores or if you do not purchase a 90-day supply of medication. one might think, well, it’s because the smaller local pharmacies have to charge more because they don’t have the volume. you’d be wrong pbms has complete control over what is paid for medications at these local pharmacies. Please let us know if you have received one of these letters from your insurance company. We all need to let our elected officials know about this push for people to choose a certain pharmacy, which is much less convenient for people in stewart co.
we recently spoke with dover family pharmacy owner marty blane who told us “we have no say in what they pay us from pbm. you have to be competitive so you sell them stuff basically , without profit”. ” Recently, a case in Ohio, according to a hospital trade publication, Becker’s Hospital Review, showed the disparities and unfair business practices of chain pharmacies. The story referenced the Columbus Dispatch newspaper and said: “Owners of small chains of pharmacies in ohio say cvs caremark’s reimbursements have dropped over the past year, making it difficult for them to stay in business. cvs caremark, the pharmacy benefit management arm of cvs health, determines reimbursement rates for three of ohio’s five medicaid providers.” The story reported that cvs caremark’s reimbursements fell from $5 to $6 above cost to about $2 above cost.” history predicted that hundreds of small pharmacies would go out of business. According to www.caremark.com, the company is listed as cvs caremark/ pbm and mail order pharmacy. They are the prescription drug benefit management subsidiary of CVS Health. So basically, they get to decide which pharmacies will get reimbursed for which drugs, and they choose their own national chain of pharmacies, CVS, as the pharmacy of choice. .coincidence? Blane told us, “they give them rebates to put their drugs on the formulary because pbms controls the formulary. according to drug companies, these rebates drive up drug costs. if drug companies don’t pay a rebate, it’s possible that your drug is not preferred and not used most patients will not buy a non-preferred drug because their copay will be outrageous a formulary is a list of drugs, both brand name and generic, covered by a certain plan the list determined by pbms when a drug is covered on the formulary, it is much more likely to be prescribed by a doctor, regardless of whether it is the best option doctors and pharmacists know that if a drug is not on the formulary, patients they can’t afford it ideally a pharmaceutical company wants to make sure their drugs are covered and offering rebates to pbms is one way of ha cerlo.
we asked blane if people benefit from rebates. He said, “It doesn’t look like they are, as copays, premiums, and deductibles keep going up. Believe me, these PBMs are mostly publicly traded for-profit companies and they’re not hurting profits. Remember, they make money.” for their premium, reimbursements and the money the plan sponsor pays to run the program plus they have virtually complete control of what they pay pharmacies for drugs when pbms needs to increase revenue they can increase copays for the patient, they pay pharmacies less for their services or increase costs for plan sponsors they are usually rejected by entities like tva or blue cross or whoever administers the drug plan those people refuse to keep paying more. like how much negotiation does a patient have in their copay amount? zero. whatever the copay is, they have to pay it. how much negotiation does a small pharmacy like mine have in the amount pbms pays me for my service? none. their contract dictates all the prices they could raise m y prices but they won’t pay a dime more. chains can bear these losses, but small pharmacies cannot. In addition, they are constantly trying to take away choice from patients by pushing patients away from small local pharmacies to chain stores or mail order pharmacies miles away.”
Drug Channels, a pharmaceutical economic analysis website, released its 2019 report on drug spending from the nation’s three largest pharmacy benefit managers: CVS Health, Express Scripts, and Prime Therapeutics. The three PBMs accounted for about 60 percent of U.S. proforma retail mail-order, long-term care, and specialty prescription equivalent claims in 2019. CVS Caremark is also listed as a mail-order prescription company. They are PBM, a pharmacy chain, and they offer mail order. We’ve all dealt with delays in the United States Postal Service, never as bad as this past Christmas season. do you really want to trust them to deliver your medication? a recent study showed that millions of Americans receive their medications through the mail, but many are forced to do so by their insurance plans or face the possibility of paying exorbitant amounts for the same medications. some are left with damaged products and life-saving drugs exposed to extreme weather conditions. A National Community Pharmacists Association (NCPA) survey of independent pharmacists confirms alarming problems with mail-order prescriptions, including late deliveries, errant deliveries, and sensitive medications left out of items. Survey shows 98 percent of community pharmacists say they’ve heard from patients whose mail-order medications arrived late or didn’t arrive at all, and 60 percent say their patients’ medications were left out due to weather , where the elements can alter the way the drugs work. It went on to state that “Ninety-two percent of pharmacists who responded to the survey said they have had to dispense a short-term supply of medication to patients while they waited for mail-houses to track their orders, and 78 percent They say they have called doctors on behalf of patients to get new prescriptions. Dover Family Pharmacy owner Marty Blane said he had to do the same. we reported last week on stewart co. residents who receive letters telling them they have to use a pharmacy chain, miles away, or order through the mail to get their prescriptions covered by their insurance.
we asked blane what exactly caremark, a multi-million dollar company, does. wondering, what happens when a person walks in to fill a prescription? He said that when someone brings a prescription to the pharmacy, “we put all the information in the computer and we send the claim electronically to the pbm, like caremark, they tell us, number one, if it’s going to be a paid claim. We’ll know instantly if it’s paid, will send back what the copay is supposed to be I don’t set those copays we don’t have a say in copays or will deny the claim entirely and will provide a reason for the denial it may be that drug is not on the formulary, it’s not a covered drug. That’s a popular denial reason.”
What I personally have been dealing with recently is insurance requesting a prior authorization (PA) from my gastroenterologist, who wanted me to take a stronger heartburn medication to protect my damaged esophagus. insurance would only cover 90 pills in a year, the doctor wanted me to take one daily to help prevent esophageal cancer. blane told me, “the most popular first denial reason is prior authorization required. what is prior authorization? they want more information from their doctor about why they chose that drug. they are not a healthcare professional, so why Question your doctor’s choice? “That’s what I can’t get people to understand. These people have business degrees. look at dollars They are not medical personnel. that’s the most popular refusal, prior authorization is required.” i finally gave up trying and so did the doctor as they can’t wait on hold for hours on end. blane said “at that point nothing can be done until that a contact be established between your insurance and the doctor. the doctor is used to talking to bluecross. his doctor is not used to talking to caremark, who never pays his doctor anything. they can’t bill them, they have to bill the medical side, they’re not used to calling caremark and telling them why they chose one drug over another, but that’s what has to happen, we can’t do it. they won’t let the pharmacy do it. Those parents, we’ve had them for years. they just got worse. there are more and more and more medicines. they’re coming up with more and more reasons, like you only get 90 pills in 365 days. three or four years ago, that wouldn’t even have been a reason. you wouldn’t have had that problem. They’re basically saying, based on who’s giving us a reimbursement, we’re going to put some of those preferred drugs and we’re going to put prior authorizations where we think they’re going to go. It’s not about medicine. they put pa’s in its place. As long as you have prior authorization, it’s not your insurance company, it’s the pbm.”
blane had a perfect example of how pbms stand to gain the most from skyrocketing drug prices. He said, “Now let me tell you what’s even more harmful to the patient. According to a recent article in Consumer Reports, the drug Humira, often used for rheumatoid arthritis, costs about $5,000 a month and every time it’s dispensed a $2,000 goes to the pbm that is processing the claim as a reimbursement now in medicare d you mentioned the donut hole let’s say a medicare d patient is required to have humira and the cost of humira is $5,000 for a supply a month .when it is dispensed at the pharmacy, on the only plan i have that uses it, i lose $5. the company that processed the prescription drug claim, pbm, gets a $2,000 refund from the company that makes humira, but they still count 5,000 something dollars for the patient’s donut hole the reimbursement doesn’t go out what happens is these reimbursements that they are receiving aren’t even counted towards the donut hole or the deductible the company never paid $5000 because rec They’re over $2,000, but they’re counting the full amount, pushing these elderly patients into the donut hole faster. once you reach that amount, you must collect a higher percentage of your own cost. They haven’t actually spent that because rebates have refunded some of it, but they don’t let you get the benefit of those rebates.”
what can we do? In the meantime, we must reach out to our representatives at the state and federal levels and tell them that it is time to regulate PBM practices. stick with those letters you’re getting from your insurance companies trying to tell you to go to a different pharmacy than the one you’re used to. state senator bill powers, office address and phone number is cordell hull building, suite 772, 425 5th avenue north nashville, tennessee 37243, phone: 615-741-2374. State Rep. Bruce Griffey’s contact information is the same address, Suite 578, Phone: (615) 741-6804. Congressman Mark Green’s contact information in Clarksville is 128 N 2nd St., Clarksville, TN 37040, phone is 931-266-4483. The phone number for U.S. Senator Marsha Blackburn’s office in Washington, D.C. is (202) 224-3344.