An article in Managed Healthcare Executive reported that over the past few years, PBMs have begun expanding from pharmaceutical management to accepting responsibility for managing healthcare’s overall costs. The article explains PBMs are engaging in ‘self-reform’ in four key ways:
Supporting Physicians and Providers at the Point of Care
According to Prime Therapeutics, “PBMs are working with all parts of the supply chain and with payers and providers to make changes quickly and thoughtfully. All parties are aligned in helping drive the best care in a consumer-focused manner at the most affordable price.”
Our response: If Webster’s Dictionary is seeking examples of doublespeak, this is a ‘prime’ example (so to speak).
PUTT regularly hears from doctors and pharmacists with evidence of the opposite. Patients are denied care, doctors’ orders are overridden by step-therapy requirements - unfulfillable during COVID - and despite executive orders from state governors, PBMs deny medication pre-fills, refills, or refuse to reimburse pharmacies for prescriptions.
These must be examples of “making changes quickly and thoughtfully” and are probably a driver behind surprisingly healthy PBM revenues during a time when everywhere else is experiencing a pandemic-driven economic downturn. One can only assume the PBM definition of “consumer-focused” equals ‘shareholder dividends’.
Assuming More Responsibility for the Total Cost of Care
PBMs claim they're “assuming responsibility for managing the total cost of care.” They purportedly do this by monitoring medication adherence, utilizing “value-based contracts”, and offering reinsurance on specialty drugs to control spending.
PBMs "monitoring medication adherence" is like cats watching a goldfish bowl - they only do what’s advantageous for themselves and there’s a good chance they’ll try to benefit when no one’s looking. And the PBM description of “value-based contracts” - paying more for medication that works, and less for medication that doesn't - defeats the purpose of lowering costs since the only way to pay less is if a treatment is a flop.
But let’s focus on reinsurance.
Reinsurance is a secondary form of insurance companies use to hedge their bets on losses. For example, a trucking company might worry about accident losses. Purchasing reinsurance would cover an additional percentage of any accident losses incurred. It’s like using a bigger umbrella in a rainstorm - the user will still get wet, but less so than before.
Reinsurance is expensive, and applying it to specialty medication is a maneuver that could only raise backend costs which would (logically) raise end-payer prices. Unless the PBM plans to take a revenue cut on each specialty drug reinsured, the employer, payer, and patient will end up being charged more to cover the expense.
Our response: Adding costs will lower drug prices? Even a first-grader understands how that math can’t work.
Providing Increased Cost Control and Transparency in Pharmacy Benefit Design
According to OptumRx, PBMs’ new benefit design allows them to “contract in a performance-driven model" where PBMs are "paid based on the ability to manage the cost and quality of care.” OptumRx claims to do this by “excluding high-cost medications with high rebates and including lower-cost generic alternatives.”
The truth is, PBMs have never disavowed rebates, they’ve simply renamed them ‘manufacturer management fees’. The money is still there - bypassing the intended recipient (the patient) and going elsewhere - usually PBM pockets. Lower-cost generics may be included in plan formularies, but without pharmaceutical companies paying some form of ‘management fees’ those generics will never make it into the hands of consumers under formulary terms.
Performance-driven metrics have been (mis)used by PBMs in pharmacy contracts for years. PBMs twist the language to justify rapidly escalating DIR fees, punitive audits, nickel-and-dime transaction fees, clawbacks, and below-cost reimbursements. To now declare that PBMs themselves will be paid based on “performance metrics” - of their own creation - is not new and is exactly what they’ve promoted themselves as doing for at least the last decade. What WOULD be new is transparency - something that hasn’t yet been tried by any of the “Big 3”.
Our response: Follow the money. Without an independently verifiable, reference-based system for cost management and quality care, PBMs are just a healthcare Ponzi scheme.
Responding to Criticism About PBM Contracting Strategies
After saying that the business model is moving away from rebates, PBMs claim (paragraphs later) that they “pass all rebate dollars back to health plans.” So which is it?
PBMs have claimed to be passing rebates back to 'clients' for years. The problem is the ‘clients’ are the insurance plans - which own or are affiliated with the PBM - so they’re really only passing the money back to themselves. It’s a vertical integration game that creates healthcare monopolies condoned by the FTC - at the expense of the most vulnerable. Employers and government entities who sign PBM contracts may think they're saving money but they're actually being swindled by confusing rhetoric.
Our response: PBM contracts are written to ensure any ‘savings’ are funneled through the contract terms into the pockets of the PBM/Insurance company. The only benefit reform these companies are engaging in is that which benefits themselves.
And Here We Go Again: Express Scripts Targets Pharmacies, Citing “Validity of Doctor-Patient Relationship” as Justification for Reclaiming Payments From 2015
In what may be the latest version of blame-shifting, Express Scripts appears to be clawing back tens of thousands of dollars on 5-year-old Tricare claims for certain prescriptions, according to complaints recently received from PUTT members.
The Department of Defense made their dissatisfaction clear regarding Express Scripts’ failure to handle compounds appropriately, ultimately costing the government billions of dollars in 2015. Since then, the handful of pharmacies that had engaged in the fraudulent scheme were shut down and the pharmacy owners sent to jail.
However, Express Scripts appears to be ramping up its efforts to claim the money it lost on the government’s behalf by dredging up old claims and forcing innocent pharmacies to pay for the PBM’s past failure.
At issue, according to Express Scripts, is the validity of the doctor-patient relationship. Express Scripts justifies reclaiming payments (taking back money for prescriptions) made 5 years ago by accusing pharmacies of not verifying the patient’s relationship with the prescribing doctor prior to filling the prescription. This rationale allows them to take payments back on claims on which Express Scripts itself failed to contain costs for the TRICARE program.
This is an especially sticky situation for patients who pay their providers in cash or choose not to use their insurance. In instances of cash payments where there may not be a lengthy paper trail, patients and providers are effectively being told they must insert the PBM into the process or risk audits and punitive fines similar to the TRICARE takebacks. Patients, physicians and pharmacies shouldn't be forced to introduce an intermediary that’s irrelevant to the patient’s treatment if the patient chooses to pay out of pocket.
While Express Scripts’ “pharmacies should have known better” rationale is weak, it hasn’t stopped the company from helping itself to pharmacies’ bank accounts. Earlier this week several webinars took place, detailing how pharmacy owners can defend themselves against TRICARE clawbacks. Unfortunately, most pharmacy owners will incur legal expenses to fight these unwarranted takebacks.
Pharmacy owners’ frustration is palpable. While most patients’ prescriptions are electronically submitted by the physician’s office (in compliance with HIPAA), PBMs are now shifting the burden to pharmacies to verify doctor-patient relationships. What’s the point of medical record technology or paying “switch” and “transaction” fees if the process itself doesn’t prove the patient-doctor relationship?
Our response is swift and direct: Express Scripts failed to do its job to contain prescription costs for the TRICARE program and is now attempting to shift the blame and the punishment to pharmacies. This is a common PBM practice: selling themselves as price negotiators and patient/plan protectors, only to point fingers when their failings are exposed.
In the coming days PUTT will issue a formal statement to the media condemning Express Scripts’ actions and will contact the members of the Department of Defense, the Senate Finance Committee and House Energy and Commerce committees, asking members to account for why the federal government continues to award contracts to Express Scripts and other bad actors when there’s documented evidence of mismanaged taxpayer funds.
PUTT will also be submitting Freedom of Information Act requests for the 2015 Tricare claims so we can attempt to understand how Express Scripts’ failure to properly manage compounded prescriptions has become the problem of community pharmacies to handle.
It is well-established that pharmacies do not control the prescriptions doctors write nor do they control PBM reimbursements (PBMs call that “proprietary” information!) These practices are strictly managed by doctors and PBMs respectively, as both groups’ trade associations have often publicly announced on digital platforms, in op-eds, and in testimony before Congress.
To now attempt to hold pharmacies accountable for the lack of oversight by Express Scripts and a few “bad apple” pharmacies (which Express did NOTHING about) is another below-the-belt punch for the frontline healthcare providers who have loyally served this nation’s healthcare system.
Community pharmacies did not create this problem and are not to blame for the actions of the primary, non-transparent entities whose contract with the federal government clearly stipulated their responsibility to properly manage taxpayer dollars.
The answer is simple: punish Express Scripts. Demand PBM transparency. It is the only way the broken prescription drug system will ever be fixed.
Frontline healthcare providers have a unique insight into the depths of systemic injustice. As independent frontline healthcare providers, we have first-hand experience of systemic injustice, and just how brutally it affects patients, especially those in communities of color, in rural areas, or those of lower socioeconomic status.
While the rest of the country is just beginning to examine how these communities have been disproportionately affected by COVID-19, the independent pharmacies who serve those populations have long been sounding the alarm about how much more damaging it will be if these patients lose their neighborhood pharmacies.
A JAMA Internal Medicine letter published last fall explored the impact of “pharmacy deserts” on poor and minority communities, gaining much media attention but little change. Last year this compelling Al Jezeera story shed light on the problem, but again, no change. As pharmacists, we are tired of the platitudes and excuses, and as we have seen in our fight against PBMs, we must work together to see progress across our country.
Pharmacy deserts are the result of the PBM business model, which relies on secrecy, exploiting loopholes, abusing pharmacies, and playing patient-steering games in the name of saving somebody - no one knows for sure who - money. These PBM-created pharmacy deserts will cause larger divides in healthcare access, inevitably creating problems across our communities that we won’t be able to fix.
The best antidote for these despicable PBM tactics is transparency. Transparency is a tenant PUTT was built on. Transparency highlights where reform is most needed. Reform should provide stability and allow equal opportunities for communities within the system, enabling stronger, more united communities to flourish. It can also bring to light to truths many people did not previously see or want to acknowledge. A complement to transparency is advocacy, and advocacy stimulates change.
Since the pandemic began, we’ve seen evidence in Florida and other states of PBMs blatantly ignoring Governors’ executive orders to allow patients to receive 90-day prescription fills and pharmacies to be paid for dispensing them. In classic passive-aggressive style, PBMs have been blocking or slashing reimbursements, forcing pharmacies to reconsider participating in the Medicaid network. Just when the positive light of community solidarity is needed most, there go the PBMs: gaming the system, squeezing every available dollar from Medicaid for themselves and forcing pharmacies to subsidize patient care off of dangerously shrinking margins.
Many who desperately depend on their local pharmacies are within the hardest-hit communities by the pandemic and its economic fallout. And while the coronavirus doesn’t discriminate on the basis of skin color or socioeconomic status, PBMs do - by using policies that all but ensure those pharmacies serving minority, rural, and poorer communities are driven out of business or scooped up by giant retailers at fire-sale prices.
PBMs will gladly route those patients into mail order, a costly and wasteful system that generates millions in additional revenue for corporate shareholders. But it's a slap in the face to the communities and patients who most need access to healthcare and an even more disturbing statement of where PBM loyalties lie. Spoiler alert: it’s not with the patients.
As pharmacists, our patients are our top priority, and we have all given so much to help our communities during these difficult times. It is not enough to simply say we support our communities. We must strive to be more inclusive and understanding of what our friends, neighbors and customers are enduring. We spend an incredible amount of time educating patients in our stores, but genuinely listening is a valuable part of educating ourselves.
Currently, with the overwhelming effects of social unrest and a worldwide pandemic, the need for reform is greater than ever. Feelings of anger, bitterness, sadness, and grief cause deep divisions that have bubbled to a breaking point. The senseless deaths of Rashard Brooks, George Floyd, and countless others in our own communities, needs to end now. Patients need accessible healthcare providers who fight for them. As community pharmacists, we advocate on behalf of our patients daily, but being the best healthcare champions we can be requires advocating for fairness in all areas, especially in the most routinely silenced segments of our own cities and towns.
The issues created by PBM biased business tactics and unfair patient treatment will never be resolved if we do not take a stand on behalf of our patients and fellow pharmacists. The past few months have forced us to put our priorities in order. Bricks and mortar can be replaced. Patient lives lost due to injustice or blind corporate greed cannot.
At PUTT we support equality for all members of our communities regardless of their skin color, age, or economic status. We are united in the need to end racism and inequality because only when everyone is treated equally can we say we are truly honoring our oath as pharmacists "to consider the welfare of humanity and the relief of suffering as (our) primary concerns".
M. Scott Newman, PharmD
Pharmacists United for Truth & Transparency
Over Half of Florida’s Community Pharmacies May Be Forced to Discontinue Participation in the State’s Medicaid Program
According to a recent survey of Florida independent pharmacies conducted jointly by PUTT and Small Businesses Aligned for Pharmacy Reform (SPAR), a Florida advocacy group, more than 60% of pharmacies surveyed may be forced to discontinue Medicaid if changes to the state’s current Medicaid reimbursement structure are not implemented soon.
Survey results indicated that 93% of the 123 Florida pharmacies that responded have had to turn away at least one Medicaid patient per month because the loss per prescription was too great, and almost one-third reported having to turn away 10 or more patients per month for the same reason.
Results also showed that pharmacy benefit managers (PBMs), who have publicly claimed to ‘put patients first’ throughout the COVID-19 crisis, blatantly ignored Governor DeSantis’ early refill executive order and current Florida statutes on patient medications, denying authorization to 61% of respondents’ Medicaid patients for 90-day supply pre-fills and/or refills during the pandemic.
According to the pharmacies surveyed, patient prescriptions most likely to be reimbursed at grossly below-cost levels include those for life-threatening conditions such as diabetes, HIV, mental health, and pediatric conditions - all drugs that fall into specialized, more expensive categories and create a substantially greater hardship on neighborhood pharmacies when required to dispense them at a loss.
If the results of this survey are any indicator, PBMs and their MCO counterparts are using the COVID-19 crisis as another way to reconfigure the healthcare industry into their own privatized profit machine.
The drug pricing model in a state-funded health plan needs to be transparent with rigorous oversight. Managed care can be non-transparent and deceptive, fooling taxpayers and consumers into thinking their medicine costs have somehow been contained, or “managed”. The survey shows that PBMs and MCOs are not obeying the law, are reducing patient access, and are forcing neighborhood pharmacies to lose money so they can maximize their record-breaking profits during a public health crisis.
The 50-question survey covered topics related to Florida Medicaid managed care reimbursements. Respondents were asked to describe the percentage of their business dedicated to Medicaid; average profit margin; estimated back-end and transaction fees (fees PBMs charge pharmacies to submit claims for reimbursement, appeal claims and other costs of business assigned by the PBM); effect on patients and on the future of their pharmacies.
The Florida Medicaid MCO survey can be found here.
On March 30, 2020, PUTT issued a formal letter including a 4-Point Plan to all state Boards of Pharmacy (BOP), Insurance Commissioners, and Governors in an effort to engage the use of independent pharmacies to combat COVID-19. The plan was simple, straightforward, and would allow pharmacies to relieve pressure on hospital systems while ensuring independent pharmacies remained solvent throughout the crisis.
PUTT heard back from a handful of states:
The Idaho, Kentucky, and Pennsylvania Boards of Pharmacy responded by thanking us for our suggestions and, in some cases, including additional helpful information while also deferring to their Departments of Insurance and/or Governors' offices. Minnesota's BOP Executive Director took the time to email a more detailed response of the state's efforts in our noted areas of concern both prior to, and during the COVID-19 crisis and included a PDF of documentation for reference going forward.
New Mexico's BOP response was unique in that not only did their Executive Director take the time to respond via email, she also immediately reached out to the state's independent pharmacy group requesting detailed information in the 4-Point Plan areas to determine next steps. Maine's BOP informed us that our plan has been added to their May meeting agenda. We will update members on the outcome of the meeting.
Arkansas, Ohio, Texas, and Kentucky Departments of Insurance responded via email with links to executive orders that have been issued regarding pharmacies' expanded roles during the COVID-19 crisis. Virginia's DOI penned a letter outlining (at the time) upcoming legislation that would rein in PBMs in the areas of licensure, audits, fees, and reimbursements. That legislation was subsequently signed by the Governor a week later.
The state of Washington's DOI sent the most impressive response to date. Their Deputy Insurance Commissioner's comprehensive 4-page letter addressed each of our points individually with regards to the state's emergency efforts and legislation - both in effect and upcoming - in each area. Disappointingly, Connecticut's DOI while acknowledging our communication, provided a "that's not in our jurisdiction" statement.
PUTT appreciates responding states' time and attention to our request amidst COVID-19. While responses were a mixed bag, any response is preferable to no response.
COVID-19 has exposed vulnerabilities in our country's healthcare system and is providing a unique opportunity to shine the light on how PBMs exploit the system for their own gain. Our 50-state outreach is only the beginning of our efforts. Even with a global pandemic occupying the country's thoughts, PUTT will continue to push for PBM reform.
Paraphrasing the immortal words of John Paul Jones, "(We) intend to go in harm's way ... Surrender? (We) have not yet begun to fight!"
It takes courage to call out cheaters, but independent pharmacies are showing courage in spades - and with inspiring results - as PBMs continue to shamelessly game the system to their own profiteering advantage. Below are just a few of the exciting victories we've been following and/or participating in since January 1:
Following the Florida Medicaid Analysis' jaw-dropping report of overt patient steering, specialty pharmacy abuse and PBM non-compliance with the state's Single Preferred Drug List, community pharmacists launched a series of local press conferences calling for immediate reform. Florida legislators have been gridlocked on the PBM reform issue since Rep. Jackie Toledo's HB 961, one of the state's most aggressive PBM legislation bills in years, was tabled in favor of a more neutral committee bill. Refusing to back down, independent pharmacies have scheduled press conferences at their stores over the next two weeks.
After a year-long effort to launch meaningful reforms in Wisconsin, Assemblyman Michael Schraa's AB114 PBM reform bill finally got its hearing this month - and saw the bill greatly reduced in strength just hours before the hearing. Undaunted, Wisconsin local pharmacists attended the hearing and testified with their patients, along with patient group representatives, pharmacy audit representatives, a former CVS employee and members of the public in a 6-hour hearing that stretched well into the evening. Assemb. Schraa's wife and daughter, whose treatment at the hands of PBMs prompted the bill, provided emotional testimony that left committee members asking how a bill that had garnered some 99 sponsors couldn't be passed as originally introduced. The following week, SB 100, the companion bill to AB114, had more than 4 hours of testimony from pharmacists, patients and advocates. Track AB 114 progress here.
In classic "zero to hero" fashion, Illinois went from virtually no protective legislation for patients and pharmacies two years ago to a series of new bills introduced this session by Senator Andy Manar. Proposed legislation would eliminate certain underhanded practices including below-cost reimbursements and forced mail order. Sen. Manar, a tireless champion for community pharmacy, has been working closely with independent pharmacies to bring change to a state where (for a little while at least) PBM reform seemed all but impossible.
With last year's victorious enactment of Senator Fred Mill's comprehensive SB 41 anti-PBM abuse legislation, Louisiana's independent pharmacies are now preparing for the possible topic of PSAO regulation - one the opposition's primary talking points - as the state's legislative session kicks off next month. Louisiana independent pharmacies are also keenly interested in helping their fellow independent pharmacies in other states draft and pass meaningful PBM reform legislation, with the end goal of bringing state reform momentum to the federal government.
California pharmacies are fighting back after the state Medicaid program decided to recoup millions lost to PBM spread pricing from pharmacies - the very people who reaped no benefit from spread pricing whatsoever. See our article (below) for how California Pharmacists Association is working to thwart Medi-Cal's misguided efforts.
To date more than 100 PBM legislation bills have been introduced, with more on the way. Look for updates on these and other inspiring victories in upcoming issues of this newsletter, and please contact us at email@example.com for more information on how these and other states are winning against PBM abuse.
Here it is, less than two weeks into the new year (new decade!) and there are already strong, positive signs in the fight for PBM reform. PUTT is making a bold prediction: 2020 is THE year!
Since January 1:
This is just the beginning. PUTT will continue to update as momentum against PBM fraud, waste and abuse continues. Look for #2020isTHEyear and post your own updates with the same hashtag. Here's to an exciting year ahead!
“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness..”. Against a backdrop as politically charged as Dickens’ A Tale of Two Cities, Congress’ latest attempt to make headway in the drug pricing debacle has resulted in two bills aimed squarely at drug manufacturers while appearing to largely overlook the now well-documented role pharmacy benefit managers (PBMs) play in escalating medication costs.
HR 3, the “Lower Drug Costs Now Act” was introduced by Speaker Nancy Pelosi with the intention of reining in rising drug prices, holding manufacturers to a price cap based on the average price of a selection of brand name medications sold to Australia, Canada, France, Germany, Japan and the United Kingdom. The bill would theoretically lower drug prices for Medicare enrollees by allowing the Centers for Medicaid and Medicare (CMS) options for negotiating pricing in line with that of other countries.
HR19, the “Lower Costs More Cures Act” introduced by Rep. Greg Walden (R-OR), also attempts to hold drug prices in check but without the government-imposed price controls. HR 19 appears to at least acknowledge certain PBM practices by including provisions calling for drug pricing transparency, a study of “pharmaceutical supply chain intermediaries and merger” and the end of “abusive spread pricing”. But like the “Pelosi Drug Bill”, it fails to address one of the central most drivers of the high prices consumers pay at the pharmacy counter: true PBM oversight and regulation.
As of last week, HR 3 has passed the House and will head next to the Senate, where it is expected to be defeated. Meanwhile the Senate Finance Committee’s “Prescription Drug Pricing Reduction Act” (the “Grassley-Wyden” bill), has been fortified to include prohibiting the PBM practice of collecting post-transaction “retroactive fees” from pharmacies, but does little to address the practice of extracting “pay to play” rebates from manufacturers in exchange for product placement on plan formularies. In its current format, the Grassley-Wyden bill is not expected to make it to the Senate floor for a vote in the near future.
Our take on the situation:
The shady, “proprietary” and “trade secret” factors that contribute to skyrocketing medication prices are a non-partisan problem that touches every American whether enrolled in Medicare, Medicaid or a private commercial health plan. By failing to directly address the well-documented profiteering tactics of a handful of Fortune 25 corporate bad actors, Congress is failing us: the small business pharmacy providers, the patients and the taxpayers.
“..It was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair … in short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only,”
To be clear, we are not ungrateful. But while we commend our federal legislators for the fair start, the fact is unless they write bills and cast votes with their consciences instead of their PAC pocketbooks, nothing will change.
We need true PBM reform, an overhaul at the state and federal level that either greatly regulates or removes PBM middlemen from the healthcare equation. Anything less will only prolong the problem.
Exceptionally smart and talented people make the health benefit decisions for their Fortune 500 corporations, but it continues to surprise us how very few ever think to push back against the multitudes of underhanded PBM practices regularly reported in the business media. Unfortunately, despite evidence to the contrary, it seems the decision-makers in these super successful companies are buying into the rhetoric, absolutely confident they got the “best deal” and have the “best discounts”.
These are real-life comments from people who refuse to believe PBMs and the brokers who control the bidding would ever manipulate the RFP process and from corporate decision-makers who are in over their heads or can’t keep up with all of the antics of the ‘PBMafia’.
McKesson Corporation is a Fortune 10 healthcare company and even they were fooled. Purely by accident, it was uncovered that McKesson’s self-insured employee medical plan was utilizing prescription benefits administered by CVS/Caremark that disadvantaged McKesson’s own customers. McKesson owns a PSAO (an entity that signs the required PBM contracts for independent pharmacies), they have independent pharmacies as customers, and they completely missed the unethical tactic that was allowing CVS/Caremark to pay themselves and all other large chains substantially more than their small chain and independent pharmacy customers.
Around 6 weeks after the discrepancy was uncovered, miraculously, all McKesson customers began to be paid on par with their large chain counterparts. McKesson Corporation has never officially commented on the issue, but a fundamental change clearly happened. It’s a prime example of how the PBM machine uses every avenue possible to cheat the corporate customers they’re supposed protect, even ones in the healthcare industry.
You may be wondering how can this happen. How can employers, even those in healthcare, be so financially exploited? How do PBMs have so much power that they can readily extract so much money from the system?
Take a look at these contracts from a PBM obtained from local government entities. Contracts like these are just one of the many power plays PBMs employ. One look and you can see they’re one-sided. What do YOU think? Share your insights & comments with us!
To view the redacted contracts discussed in this article, click Here
Like an evil chess Grandmaster, PBMs are incredibly adept game players, exercising diabolical patience and foresight as they craft the long-term cons they sell as "saving money" on behalf of consumers and plan payers.
Pharmacists are well aware of the complicated tactics that make up the PBM playbook and result in unnecessary millions charged to end payers every year.
Knowing patients and end payers are being ripped off is one thing. Calling attention to the rip off is an entirely different - and extremely risky - matter. But a PUTT member pharmacist is taking a new approach: documenting the perpetuated spread pricing that occurs between the deductible and benefit phases in a patient's plan, and reminding patients they have the right to request a "receivables statement".
What is "Perpetuated Spread Pricing"?
Imagine this scenario: you're a consumer with normal prescription drug coverage through your employer. It's late January, time for your monthly medication refill. You go to your local drugstore, the pharmacist inputs the script and updates your insurance as per usual. Because you're in the deductible phase, you're charged the full copay and the PBM bills your plan at the contracted rate. You and your health plan repeat this process monthly until your deductible is met and your copay is $0.
Now imagine your coworker, a member of your same insurance plan, who takes the same medication and dosage but has met their deductible a little earlier than you. They have a $0 copay and the health plan pays the same contracted rate as before, right?
When the pharmacist inputs your co-worker's information, it returns pricing based on what should be "contract pricing" but after the deductible is met, the system automatically prices that same medication at "MAC pricing".
This behind-the-scenes switch allows PBMs to continue to charge the health plan the higher contracted rate, but reimburse the pharmacy substantially less, resulting in greater spread - and therefore increased profits - to the PBM.
When the patient is in the deductible phase, they very often pay an average of 235% more for medication that, when the deductible is met, the PBM is now indexing against MAC, and now paying itself more by charging the health plan the contracted rate and reimbursing the pharmacy for the lower-priced MAC rate.
Perpetuated spread pricing is a direct violation of the contract between the PBM and the consumer's insurance plan, especially since the medication price charged to the consumer between the deductible and benefit phases is substantially different. Unless two patients with the exact same prescription under the exact same group insurance plan come into the same pharmacy to fill their identical prescriptions at the same time, no one might ever catch on to the discrepancy.
It's convoluted consumer defrauding at its finest.
Pharmacists legally aren't allowed to disclose this level of information to consumers without risking multiple lawsuits from the PBMs and insurers. The only way for consumers to actually ensure they're not being overcharged is under new state & federal anti-gag clause legislation.
Most states have recently passed anti-gag clause legislation. This same legislation allows patients to request a receivables statement when they fill a prescription. If a consumer were to do this each time they filled their prescriptions, they could see actual prescription charges and could compare prices against what their plan says they should be charged.
The PUTT member pharmacist discovered this new level of consumer fraud because it was his plan - and one of his co-workers on the same medication - who were charged the different amounts for the same prescription. He filed a formal complaint with his state's department of insurance and was told he "wasn't considered a consumer" and therefore the complaint was thrown out.
PUTT encourages members to review your state's anti-gag clause legislation to check for the receivables statement language, and then inform patients of their right to know how much they and their health plan are being charged for their prescriptions.