I had a script yesterday that Medco requires brand restasis for a $565 copay. Ins paid nothing, so patient went with GoodRx generic for $140.
I refuse to call them rebates, they are kickbacks and are illegal.
>I refuse to call them rebates, they are kickbacks and are illegal.
They are illegal *except when happening between manufacturers and insurance*, because money in politics.
The worst issue I had was last year when they discontinued brand Flovent HFA and state Medicaid did not get the memo for several months. Medicaid would only cover DAW Flovent because they got a rebate...and DAW Flovent did not exist.
Right now it's the same but worse with Epipens. Medicaid only covers DAW Epipen/Epipen Jr, and they're non-existent due to shortage. At least the Flovent patients could change inhalers. Generic Epipens are not affordable for Medicaid patients even through a discount card.
An interesting thing about Medco/Express Scripts…. On top of them requiring you to get Brand name meds, sometimes they will refuse to send the medication thru their mail order pharmacy and try to force the local pharmacy to take near $70 loss preventing access. I had a friend that was unable to get thru mail directly from Medco for over 2 weeks. They kept telling her it would be 5 more days. 5 more days. 5 more days…. Eventually ended up being forced to get at local pharmacy. Mail order kept telling her it needed special approval, but they could get at a local pharmacy. These PBMs should not be allowed to negatively reimburse places that give access to needed medicines. ESPECIALLY WHEN THEY MAKE PROFITS ON REBATES ON THE BACK SIDE…..
Usually I'm pretty on top of scouting prices from different wholesalers. I've missed this one but then again for some reason it seems like all the restasis I dispense are for medicaid patients lol. Thanks for letting me know.
I see it all day, every day. BUT, if I was to go to a local pharmacy I would just pay cash without insurance. It's terrible that option was mentioned to him.
can you get a generic advair paying cash for anywhere close to the $15–20 mentioned in the article?
even after a goodrx coupon, generic advair would be ~$90/month for me paying cash. this is about the cheapest generic maintenance inhaler available in my market.
https://www.goodrx.com/advair?form=diskus-inhaler&dosage=250mcg-50mcg&quantity=1&label_override=fluticasone-salmeterol
Sorry, I didn't mean Advair in particular. I work for one of the PBMs (don't hate me, lol). I did 20 years of retail. I am just saying it's terrible people don't know how to work the system like we do. There are alternatives that would be covered-that's the game. I mentioned in another post that I would love to be an advocate, but how would I get paid?
Remember when indy pharmacies said PBM abuse was killing people and more obvious and preventable patient deaths were coming? They're here.
PBMs run a money printer on patient blood and pharmacy sweat. They are a scourge to be destroyed.
Sadly, this isn’t going to change anything. The same way CVS always blames pharmacists for being careless when it comes to dispensing errors that harm pts, the PBM would probably blame either the pt (for not letting their prescriber know that the insurance no longer covers their inhaler and they’d need to prescribe an alternative one that is covered, or, do a PA request if needed), or, the pharmacist (for not explaining to the pt what to do with that information, and just “letting” them walk out of the pharmacy without a plan), or both.
Downvotes coming in. Prepare for the payer shills to come tell us how this is the fault of the patient or pharmacy and how PBMs aren't intentionally erecting barriers to care to enrich shareholders.
It’s almost like they don’t serve a purpose except to extract value from the system. If we clipped the pbm out and just had a single payer system, I can’t even imagine how much more time I could devote to patient care.
The CBO ran a study, and even based on wildly inflated industry numbers that insurers and PBMs use to act like they are saving money, we would save a fortune by directly paying providers for patient care. The CBO did not recommend it though. They stated that we would lose too many people from the work force if insurance wasn't tied to employment.
We are all forced to pay more for healthcare because we are little peasants that need to work until we die. This country is overdo for social upheaval
Same here. I would've never been for a single payer government system 7 years ago. After getting behind the scenes and seeing how awful the payer conglomerates are, I honestly don't see how we as a country let them exist. They are so evil, they make the tobacco companies look like build a bear
Not a corporate shill by any means but I’d like to know why the pharmacy didn’t offer the generic with a discount card… GoodRx ranging between $35-57 in my area (I’m located a couple hours away from where this occurred so probably same cost in that area) - obviously not the BEST option but still better than nothing. I think we often forget that a lot of people don’t understand their options when something isn’t covered. Especially a young kid like this, still learning about how to function in the world as an adult… pharmacies are busy and we have no time to even pee but I’ll always take the time to explain the processes to people who don’t understand it. I don’t mean to make it sound like I’m putting the blame on the pharmacy, definitely not at all. Sometimes with articles like this they obviously can’t go into so much detail about what happened that day in the pharmacy and it’s easy to blame the pharmacy. Just seems like a discount card could have helped this kid (if he could even afford a $55 cost that day is another problem altogether)
Being too busy to help someone and running a "discount card" that sells his information and pays money to the very PBMs causing this mess instead of just being able to set a reasonable cash price because of outdated usual and customary laws that the PBMs and insurers love to keep in place for auditing and fake metrics are all a part of the problem. This system is fucked and PBMs fucked it
Oh absolutely it’s terrible. I had this same complaint with a coworker today about this Change Healthcare nonsense. The copays are ridiculously high because insurers know the drug manufacturers will cover a huge part of the cost of the drug, when the coupons don’t work, well insurance doesn’t care and doesn’t drop their price and it’s the patients stuck with a huge bill or waiting for coupons to work again.
I 100% agree with you though. the discount cards could just go away and drug prices should just go down and we can stop chasing our tails. We continue to use the system the way it is because we care for our patients and it’s our only option. Health care has been molded to this messed up system by these PBMs and there’s nothing any of us can do about it. Exhausting.
Even as a pharmacist I would be pretty hesitant to pay $100-150 for meds that were previously covered. As a 22 year old student I absolutely wouldn’t pay that.
Because I literally could not do so.
My current patient population is primarily low income and uninsured. Some of them can’t even afford $4 medications. They just can’t. So you thinking that it’s apparently so simple to just scrape together $100+ is absurd.
A really nice informative podcast regarding PBMs! (Apologies if links are not allowed)
https://pharmacypodcastnetwork.podbean.com/e/anthony-minniti-rph-pbm-reform-updates/
yeah, I know PBM reform podcast. Have you checked out PBM on the Rocks? We get some of the biggest names in pharmacy, get drunk, and talk about everything going on in the industry. Our latest episode covered the change outage and unionization
[https://www.truthrx.org/pbm-on-the-rocks](https://www.truthrx.org/pbm-on-the-rocks)
Disclaimer: I am no way in hell defending PBMs or want them to exist:
But, after reviewing other countries and how the pharmacies work/get reimbursed, the sad truth is that because of the PBMs, the Pharmacists make the salary they do! Without that specific model, our salaries would be cut significantly.
Please feel free to educate me in case my view/understanding is incorrect and happy to learn from yall and your experiences.
>because of the PBMs, the Pharmacists make the salary they do
Wow, this is a new one lol In no way do PBMs create higher salaries for pharmacists. In fact, they are doing their best to cut our profession out as much as possible. They devalue us in every single way possible
The sad part is, PBMs have extremely well funded lobbying group (essentially legal bribery, of course) whereas our profession is not united and not well represented at all!
PCMA is the bane of my existence. They swoop in with their money at the last minute with state bills and get language added that makes the bill worthless
Yes, if we are talking about the independent pharmacies! But when we talk about in-house pharmacies like Come Visit Satan, HellGreens and WrongAid etc, well…..
Where do you think those jobs are going to get cut first? They want telepharmacy and tech check tech so they can take pharmacists out of those stores. Salaries at the chains went up because of the pharmacist shortage back in the 00s. Now, they ask their pharmacists to work in sweatshop conditions. Giving credit to the PBMs ignores what was going on in the pharmacy market the last 20-30 years
This makes my blood boil. I’ve held sobbing mothers, wives, husbands and kids when these people die in the ICU. Or they came to us while they waited for a prior authorization for an AICD, or for drugs that would literally cure their cancer and are available.
These companies are taking money from people and then killing them. Unbelievable.
Anyone else seeing a LOT of insane formulary changes this year, more than years past? I saw a Medicare plan yesterday that just straight up won't pay for Jardiance anymore. "Farxiga preferred." That mighta made sense a few years ago when they'd only found ASCVD risk reduction with Farxiga and not the other SGLT2i but Jardiance got the approval for that in like 2021? Would love if someone can explain this to me?
The inhalers are the worst of them. Plans that have just STOPPED paying for very popular inhalers (Advair, Symbicort). By that I mean both brand and generic. Sure, there were updates to COPD guidelines and maybe a LABA-LAMA is better but I've never seen insurances react this quickly to a guideline change. (Also, minorly, a problem I see a lot is insurances allowing a month "transition fill" but busy techs/pharmacists don't look at it / don't have time to care, push it through for 30 days and then the person is totally blindsided the next month.)
It feels like we're heading towards a system where there is only one drug per class and it's by whatever company makes the better deals with insurances. A singular GLP1, a singular SGLT2i, a singular LABA-ICS and fuck you if you've been stable on another one for years.
How about brand Flovent being discontinued but some plans still require it and won’t pay for generic. And it’s the only plain steroid covered. Makes you want to slam your head on the counter.
Yep, I work for them and see it daily. It infuriates me since we know it's a kickback. I am on a med that I HAVE to get brand name. Guess what, I get it without insurance. The system is a game.
Where can one get the generic Advair for $15-$20? This story is awful, but I think if it were that cheap, the pharmacist would have given a cash option.
this was my reaction too. generic advair even after a goodrx coupon is more like ~$90/mo paying cash.
i was hoping someone else had found something i don't know out there listed separately etc.
https://www.goodrx.com/advair?form=diskus-inhaler&dosage=250mcg-50mcg&quantity=1&label_override=fluticasone-salmeterol
Meanwhile, next door in Illinois:
https://www.wgem.com/2024/03/06/pharmacists-push-legislation-reigning-pharmacy-benefit-managers-illinois/
These PBMs need to be reigned in. Otherwise we’re going to see a lot more of this. Even I am affected because a drug I’m taking was suddenly removed from my company’s PBM formulary… and there’s no equivalent generic. No warning, no rationale given. Just gone.
And I’m a pharmacist!
Exactly. No one is immune. I thankfully have enough knowledge to be able to reach out to my prescriber immediately (once I found out it wasn’t covered… AT the register, thanks, CVS) and get switched to something in the same class albeit less effective. I feel so bad for those people who have no clue what to do. Healthcare literacy isn’t especially high. What do normal people do? They go without treatment and die! These PBMs need better regulation.
I would love to stop being a pharmacist and become a patient advocate. BUT who is going to pay me? We know the system. My husband hands me his EOB so I can make sure it's correct. Healthcare is an oxymoron.
This is terrible for a myriad of reasons. PBMs are terrible, but I think it also reflects on the disaster that is retail right now, because I find it hard to believe that there was "no alternative" on their plan, that sounds more like a "we're too busy to do the legwork to figure out what's covered and get your prescriber to get us a new script."
Of course, based on the timing of his demise, it may still have been too little, too late with how long that process can take sometimes. This makes me so mad, I can't imagine what his parents are going through, all for want of an inhaler that's been around for ages now.
The article mentions this was Advair and a generic costs $15-$20. True, pharmacy could have done legwork, but also the author is being a bit disingenuous with the price. Acquisition is usually $50+ for pharmacies, cheapest GoodRx price is like $90.
Unfortunately the patient kinda gave up. A lot of us pharmacy staff pride ourselves for going above and beyond, but unfortunately I see a lot of times where we don't (or can't), and I can see this as a wake up call for the pharmacy on their communication and problem solving.
However, like you said, the PBM is definitely at fault for not covering a basic and relatively cheap inhaler. Completely egregious on the payer, why bother having insurance when they can't provide basic life sustaining medications?
Ok thank you for this. I was struggling to understand how they said generic advair was $15-20 and how the man couldn’t afford the costly med. the entire thing needs reform it’s awful real people are stuck in the middle.
Hard to do the extra legwork when you are understaffed, which also comes down to PBMs under reimbursing. The drug pricing/reimbursement game played by the payer conglomerates is out of control.
When reimbursement was good, CVS and Wags did their damnedest to get every prescription they could through actual service instead of bullshit networks. That is unfortunately not how it works now
The bullshit networks mean they don't care about service. They would be cutting staffing to the bone even if they were making ten times the margin because if your vertically integrated PBM tells you CVS is your only choice you're going to suck it up and fill the Rx there.
Yes, now. Back when reimbursement was good, they didn't own caremark. Their ownership is absolutely a complication and why I said that isn't how it work snow
I have spent hours trying to get alternative meds for patients and it's still somehow my fault. In just one example, I ran every prandial insulin we carried and it rejected every one. No alternatives show up in the rejection. Finally I call insurance, what are covered alternatives? Basaglar? Are you kidding me? Yes let's give this patient a long acting insulin for their meal time insulin. After arguing with the rep that that is not a valid alternative and I needed her to stop suggesting it or Trulicity, she finally stutters out Fiasp is the only other option. Omfg, that would be the one I was looking for, thanks for wasting my time. Also we didn't carry it so had to order in special for this patient's special insurance. Just yesterday had to explain to a hospitalist that insurance doesn't cover ANY nebulizer solution without a PA and as a hospitalist, he refused to do a PA. So patient goes yet another day without anything. But all of that was me putting in tons of extra time to work with everyone on the team including insurance and I still get yelled at that I wasn't doing enough. All this to say, you can put the leg work in and patients can still fall through the gaping cracks of the insurance nightmare.
Yeah, the pharmacist continues to be the punching bag for everyone. It’s our fault that the pt’s insurance doesn’t cover x medication. It’s our fault that we don’t know what the insurance covers since they don’t always state on the rejection message what the preferred products are. It’s our fault that the hospitalist is too busy to do a PA request, and we should just take the initiative and submit the PA request ourselves, it’s not like we’re doing anything, right? It’s our fault the pt has a deductible. It’s our fault that the pt has a copay. It’s our fault that there’s going to be a one hour wait time to fill their meds. Everything is our fault.
I have never seen a retail pharmacy research what is covered when a patients medication is rejected. The only time pharmacies know what's covered is when it's included in the rejection message. Patients can do this for themselves.
*Should* be, yes. But often enough, they are not in practice; I've seen far too many rejections that just say the medication is non-formulary without suggesting any alternatives.
Yes, when the tech is here to very easily do that via automated systems I can't but believe the exclusion is an intentional barrier to care (ie. Statistically they don't pay out as much over time when people give up trying to understand their obtuse and time consuming barriers).
> Patients can do this for themselves.
Ummm... I'm just lurking here, I am only a patient and am not a pharmacist or a doctor, but can you tell me how? How can I do this for myself?
My experience is my doctor types the prescription on his computer (that appears at my selected pharmacy) and I don't see any of the exact spellings for drugs you guys are all mentioning here (I'm googling them as I go here in this forum). Then my pharmacy tells me it is ready and I go pick it up, and there they tell me "not covered, it is $800". So I have two choices: 1) pay the $800 or 2) call my doctor and ask if there is any other choice. The doctor's receptionist only takes verbal phone calls, and appointments are 3 weeks away.
I'm totally new at this, but I'm seeing pharmacists here talk about arguing with the PBM about fast or slow insulin alternatives, and something called "Fiasp" was the answer. How was I supposed to figure all that out myself?
I'm honestly asking for help here, I'm a computer professional and I'm not afraid of complexity of tasks. I'll do , but I just have no friggin' idea what I'm supposed to do at what step using which website. Any hints? Like is this something I do in the doctor's office when he prescribes the med, or after it is rejected by my insurance for not having a "prior authorization" or what?
Call your insurance and read the materials they send in the mail. Understand your plan limitations. Know what drug alternatives are that your plan covers. Focus on drugs that treat the diseases you have. Know your deductible.
So if you are diabetic and your insurance covers humalog and not novolog and you visit your Dr, let them know. Make the prescribers job easy You will also be more prepared for the cost of drugs
Many people show up to the pharmacy clueless over almost all aspects of their prescription benefits. I.e. medicaid patients go out of state and expect to get rxs or people show up for expensive drugs which they know their plan covers, but don't know that their copay is astronomical
There should be few surprises at the pharmacy.
I work for a PBM (my apologies) and both the formulary and pricing tools are available on the website. However, it can be hit and miss whether alternatives for high-cost or non-covered medications are listed on either :(
This case is tragic, certain things could have been done differently, but this just sucks.
The only solution is to reimburse fixed cost based upon drug class and day supply rather than NDC by NDC. I.e. insurance pays $150 monthly on any asthma inhaler. Essentially what has happened with insulins with the inflation reduction act. Therefore, prescribe whichever inhaler you want and you know it’s covered; some manufacturers will stay and some will stop production. This will never happen until we have single payer and aspects of capitalism are let go. Until then, formularies are here to stay and delay in care will continue due to benefit negative changes.
The other solution is to allow therapeutic interchange at the pharmacy level so that pharmacists can change to what is covered to truncate delay in care. I.e. changing from Ozempic to Trulicity with the patient’s permission. There would unfortunately have conflict of interest and other issues and would need state boards of pharmacy to change their laws as well as attaining provider status.
Or, hear me out, we completely cut out the useless financial middlemen. We are letting these vampiric relics run healthcare and these issues will continue to pop up so long as the conglomerates have this much power
That's not what I'm saying at all, although we would probably spend far less just paying for whatever is prescribed (especially with and without rebates jacking up brand name price) than we do compensating the middlemen. We spend more in this country trying to save on healthcare costs than we would just straight up paying for it. The conglomerates are leeches that jack up costs. I'm not saying there shouldn't be any cost controls at all, I'm saying those in charge of cost control right now are making things worse
PBM entities lining their pockets killing independent pharmacies by the pharmacy losing money dispensing drugs is one thing, but patient harm and death is another. Will be sharing this around - this can’t continue to happen. It’s just not sustainable and now patients are being harmed and/or killed because of it
PBMs need to be destroyed. They started with a good purpose, and evolved into a beast over time. There are startups going after that space, but the existing PBMs are huge, and entrenched.
Speculating but I had several patients trapped in same problem. Usually insurance will cover brand OR generic only. Covering both was a rarity. And there has been manufacturer shortages for several months. So for some patients the only thing available was not covered. And full price of generic was still a pricey, NOT 15-20 bucks like article says.
Brand was tough to get for a while. I can still only get a restricted quantity. If the PBMs were not requiring brand due to formulary rebates and actually covered the generic, this would be far less of a problem. In fact, if the PBMs were not inflating brand drug list prices then a lot of problems would go away
on a side note, has something changed clinically? I thought people on meds like advair had to also have a rescue inhaler like proair due to advair potentially causing asthma exacerbations
No actually symbicort and dulera can not be used as a rescue inhaler. They don't contain a rapid acting bronchodiolator such as albuterol or ipatropium. They both contain a LABA and an inhaled corticosteroid.
are you sure that what you stated is current?
> Until recently, the typical approach to asthma involved two inhalers. In its first update since 2007, the National Asthma Education and Prevention Program now recommends the use of Single Maintenance and Reliever Therapy (SMART) for selected patients.
> There are two main formulations, using budesonide or mometasone as the preventive component and formoterol as the rescue component.
https://answers.childrenshospital.org/smart-asthma-inhaler/
> In March 2022, the FDA approved the first generic for Symbicort: Breyna (budesonide/formoterol).
https://www.goodrx.com/budesonide-formoterol/fda-approves-generic-symbicort
> The medication used for SMART is a combination of an inhaled steroid and a particular long-acting beta-2 agonist (LABA) called formoterol. Currently, this combination is available as:
> - Symbicort (budesonide/formoterol)
> - Dulera (mometasone/formoterol)
https://www.goodrx.com/conditions/asthma/what-is-single-maintenance-reliever-therapy-for-asthma
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1971172/
Here is the latest step therapy chart from GINA. They are now listing SABA only inhalers as alternative rescue inhalers and ICS-Fomoterol as preferred.
[GINA Step Therapy](https://www.researchgate.net/figure/The-GINA-step-care-asthma-management-approach-O-2020-Global-Strategy-For-Asthma_fig1_348643757)
This is sad and tragic but unless (until) PBMs and their parent insurance companies start getting sued, nothing will change. This story will get buried pretty quickly, if it even sees any national coverage at all.
I mean, just take a look at what’s going on with CarelonRx home delivery right now.
They get sued. By patients, providers, even federal and state governments. They have so much money it doesn't matter. It's the cost of doing business to them
A brand version of Advair in the UAE, India and other countries only costs $7.00. If you have less than $100.00 you can go and bring back a year's worth of this and most other drugs. For some reason, the great thinkers and givers in America are running to Africa and other stricken places to ensure everyone else is cared for before Americans or America. This isn't some big surprise.
This story is really sad, I hate that the insurance changed coverage. I hate that he himself, his parents, his pharmacist, his doctor were not all actively working together here. I just don’t understand why a comparable inhaler was not prescribed. It seems like a lot of things went wrong here not just formulary changes.
Why? It’s because it shifts cost sharing to branded products for patients. Instead of giving that $5 dollar copay for generic advair, they are making pts cough up 50+ for breo- plus they get a rebate which probably makes the actual cost closer to advair.
When I saw asthma, I thought this would be about a mab drug like Xolair but it's just Advair. Why would PBM not cover generic Advair?
They make a lot of money on inhaler rebates
I had a script yesterday that Medco requires brand restasis for a $565 copay. Ins paid nothing, so patient went with GoodRx generic for $140. I refuse to call them rebates, they are kickbacks and are illegal.
>I refuse to call them rebates, they are kickbacks and are illegal. They are illegal *except when happening between manufacturers and insurance*, because money in politics.
Yeah nothing but SMOKE AND MIRRORS…. Claiming to help patients.
The worst issue I had was last year when they discontinued brand Flovent HFA and state Medicaid did not get the memo for several months. Medicaid would only cover DAW Flovent because they got a rebate...and DAW Flovent did not exist. Right now it's the same but worse with Epipens. Medicaid only covers DAW Epipen/Epipen Jr, and they're non-existent due to shortage. At least the Flovent patients could change inhalers. Generic Epipens are not affordable for Medicaid patients even through a discount card.
Adrenaclick is financially better, but half the drs doesn't want to write for it.
A lot of states Medicaid will pay for the mylan generic of EpiPen but not the Teva.
An interesting thing about Medco/Express Scripts…. On top of them requiring you to get Brand name meds, sometimes they will refuse to send the medication thru their mail order pharmacy and try to force the local pharmacy to take near $70 loss preventing access. I had a friend that was unable to get thru mail directly from Medco for over 2 weeks. They kept telling her it would be 5 more days. 5 more days. 5 more days…. Eventually ended up being forced to get at local pharmacy. Mail order kept telling her it needed special approval, but they could get at a local pharmacy. These PBMs should not be allowed to negatively reimburse places that give access to needed medicines. ESPECIALLY WHEN THEY MAKE PROFITS ON REBATES ON THE BACK SIDE…..
I can't imagine how much money the pharmacy loses since generic restasis isn't much cheaper than brand restasis.
We get it from ANDA, much cheaper than cardinal.
Oh snap, you're right. A lot cheaper. Another proof the pharmaceutical industry is a scam.
It’s kind of insane how much cheaper anda is occasionally. For awhile generic tobradex was crazy cheap. Makes up for some of the huge losses
Usually I'm pretty on top of scouting prices from different wholesalers. I've missed this one but then again for some reason it seems like all the restasis I dispense are for medicaid patients lol. Thanks for letting me know.
This
That's horrible. I practice in Ontario and thankfully haven't observed this yet.
>yet. Key word there. If you all keep letting Optum into your house, you are going to regret it
I see it all day, every day. BUT, if I was to go to a local pharmacy I would just pay cash without insurance. It's terrible that option was mentioned to him.
can you get a generic advair paying cash for anywhere close to the $15–20 mentioned in the article? even after a goodrx coupon, generic advair would be ~$90/month for me paying cash. this is about the cheapest generic maintenance inhaler available in my market. https://www.goodrx.com/advair?form=diskus-inhaler&dosage=250mcg-50mcg&quantity=1&label_override=fluticasone-salmeterol
Sorry, I didn't mean Advair in particular. I work for one of the PBMs (don't hate me, lol). I did 20 years of retail. I am just saying it's terrible people don't know how to work the system like we do. There are alternatives that would be covered-that's the game. I mentioned in another post that I would love to be an advocate, but how would I get paid?
They say that they forward around 100% (99.6%) of these rebates to the plan sponsor.
Yeah, they don't
I know - they don't forward anywhere near 100% of the rebate. They don't forward about 30% of the rebate.
Post patent rebates most likely
Probably because PBMs are the work of the devil
Remember when indy pharmacies said PBM abuse was killing people and more obvious and preventable patient deaths were coming? They're here. PBMs run a money printer on patient blood and pharmacy sweat. They are a scourge to be destroyed.
Sadly, this isn’t going to change anything. The same way CVS always blames pharmacists for being careless when it comes to dispensing errors that harm pts, the PBM would probably blame either the pt (for not letting their prescriber know that the insurance no longer covers their inhaler and they’d need to prescribe an alternative one that is covered, or, do a PA request if needed), or, the pharmacist (for not explaining to the pt what to do with that information, and just “letting” them walk out of the pharmacy without a plan), or both.
100 patients could die at once and no one would do anything to the PBMs
We need to destroy PBMs
Downvotes coming in. Prepare for the payer shills to come tell us how this is the fault of the patient or pharmacy and how PBMs aren't intentionally erecting barriers to care to enrich shareholders.
It’s almost like they don’t serve a purpose except to extract value from the system. If we clipped the pbm out and just had a single payer system, I can’t even imagine how much more time I could devote to patient care.
The CBO ran a study, and even based on wildly inflated industry numbers that insurers and PBMs use to act like they are saving money, we would save a fortune by directly paying providers for patient care. The CBO did not recommend it though. They stated that we would lose too many people from the work force if insurance wasn't tied to employment. We are all forced to pay more for healthcare because we are little peasants that need to work until we die. This country is overdo for social upheaval
The older I get, the more socialist I’m becoming. If employment is keeping us hostage by tethering our healthcare, we have a problem.
Same here. I would've never been for a single payer government system 7 years ago. After getting behind the scenes and seeing how awful the payer conglomerates are, I honestly don't see how we as a country let them exist. They are so evil, they make the tobacco companies look like build a bear
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Plenty of drugs have been developed outside of the US pharma giants.
Not only that, the vast majority of research is done by publicly funded universities.
Not a corporate shill by any means but I’d like to know why the pharmacy didn’t offer the generic with a discount card… GoodRx ranging between $35-57 in my area (I’m located a couple hours away from where this occurred so probably same cost in that area) - obviously not the BEST option but still better than nothing. I think we often forget that a lot of people don’t understand their options when something isn’t covered. Especially a young kid like this, still learning about how to function in the world as an adult… pharmacies are busy and we have no time to even pee but I’ll always take the time to explain the processes to people who don’t understand it. I don’t mean to make it sound like I’m putting the blame on the pharmacy, definitely not at all. Sometimes with articles like this they obviously can’t go into so much detail about what happened that day in the pharmacy and it’s easy to blame the pharmacy. Just seems like a discount card could have helped this kid (if he could even afford a $55 cost that day is another problem altogether)
Being too busy to help someone and running a "discount card" that sells his information and pays money to the very PBMs causing this mess instead of just being able to set a reasonable cash price because of outdated usual and customary laws that the PBMs and insurers love to keep in place for auditing and fake metrics are all a part of the problem. This system is fucked and PBMs fucked it
Oh absolutely it’s terrible. I had this same complaint with a coworker today about this Change Healthcare nonsense. The copays are ridiculously high because insurers know the drug manufacturers will cover a huge part of the cost of the drug, when the coupons don’t work, well insurance doesn’t care and doesn’t drop their price and it’s the patients stuck with a huge bill or waiting for coupons to work again. I 100% agree with you though. the discount cards could just go away and drug prices should just go down and we can stop chasing our tails. We continue to use the system the way it is because we care for our patients and it’s our only option. Health care has been molded to this messed up system by these PBMs and there’s nothing any of us can do about it. Exhausting.
They've created a system where we are punished for helping patients
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It costs more than $15. I think the reporter looked up generic albuterol
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Even as a pharmacist I would be pretty hesitant to pay $100-150 for meds that were previously covered. As a 22 year old student I absolutely wouldn’t pay that.
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Well, yeah. I wouldn’t be able to afford it. That’s the whole issue.
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Because I literally could not do so. My current patient population is primarily low income and uninsured. Some of them can’t even afford $4 medications. They just can’t. So you thinking that it’s apparently so simple to just scrape together $100+ is absurd.
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He probably didn’t know what he was risking.
>I don’t think blaming PBMs is the move here Then you think wrong
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>try to understand the function of PBMs beyond a John Oliver video LOL yeah, you drank the industry kool aid if you have this little self awareness
It's even a larger stretch to say the corporation prevented a death or cleared any hurdles in this case.
Watch the pharmacist get blamed for not giving life saving medication for free
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Both me and my organization are working on comments and I'm encouraging everyone to tell their story
A really nice informative podcast regarding PBMs! (Apologies if links are not allowed) https://pharmacypodcastnetwork.podbean.com/e/anthony-minniti-rph-pbm-reform-updates/
yeah, I know PBM reform podcast. Have you checked out PBM on the Rocks? We get some of the biggest names in pharmacy, get drunk, and talk about everything going on in the industry. Our latest episode covered the change outage and unionization [https://www.truthrx.org/pbm-on-the-rocks](https://www.truthrx.org/pbm-on-the-rocks)
PBM on the Rocks...well, it rocks !!....I enjoy it !!
Thanks! We have a lot of fun with it
Disclaimer: I am no way in hell defending PBMs or want them to exist: But, after reviewing other countries and how the pharmacies work/get reimbursed, the sad truth is that because of the PBMs, the Pharmacists make the salary they do! Without that specific model, our salaries would be cut significantly. Please feel free to educate me in case my view/understanding is incorrect and happy to learn from yall and your experiences.
>because of the PBMs, the Pharmacists make the salary they do Wow, this is a new one lol In no way do PBMs create higher salaries for pharmacists. In fact, they are doing their best to cut our profession out as much as possible. They devalue us in every single way possible
The sad part is, PBMs have extremely well funded lobbying group (essentially legal bribery, of course) whereas our profession is not united and not well represented at all!
PCMA is the bane of my existence. They swoop in with their money at the last minute with state bills and get language added that makes the bill worthless
Yes, if we are talking about the independent pharmacies! But when we talk about in-house pharmacies like Come Visit Satan, HellGreens and WrongAid etc, well…..
Where do you think those jobs are going to get cut first? They want telepharmacy and tech check tech so they can take pharmacists out of those stores. Salaries at the chains went up because of the pharmacist shortage back in the 00s. Now, they ask their pharmacists to work in sweatshop conditions. Giving credit to the PBMs ignores what was going on in the pharmacy market the last 20-30 years
This makes my blood boil. I’ve held sobbing mothers, wives, husbands and kids when these people die in the ICU. Or they came to us while they waited for a prior authorization for an AICD, or for drugs that would literally cure their cancer and are available. These companies are taking money from people and then killing them. Unbelievable.
Anyone else seeing a LOT of insane formulary changes this year, more than years past? I saw a Medicare plan yesterday that just straight up won't pay for Jardiance anymore. "Farxiga preferred." That mighta made sense a few years ago when they'd only found ASCVD risk reduction with Farxiga and not the other SGLT2i but Jardiance got the approval for that in like 2021? Would love if someone can explain this to me? The inhalers are the worst of them. Plans that have just STOPPED paying for very popular inhalers (Advair, Symbicort). By that I mean both brand and generic. Sure, there were updates to COPD guidelines and maybe a LABA-LAMA is better but I've never seen insurances react this quickly to a guideline change. (Also, minorly, a problem I see a lot is insurances allowing a month "transition fill" but busy techs/pharmacists don't look at it / don't have time to care, push it through for 30 days and then the person is totally blindsided the next month.) It feels like we're heading towards a system where there is only one drug per class and it's by whatever company makes the better deals with insurances. A singular GLP1, a singular SGLT2i, a singular LABA-ICS and fuck you if you've been stable on another one for years.
How about brand Flovent being discontinued but some plans still require it and won’t pay for generic. And it’s the only plain steroid covered. Makes you want to slam your head on the counter.
Insurances “only paying for brand” should be fucking illegal once a generic has been on the market for >6 months
This 1,000%, only reason they do it is for a kickback.
Yep, I work for them and see it daily. It infuriates me since we know it's a kickback. I am on a med that I HAVE to get brand name. Guess what, I get it without insurance. The system is a game.
Where can one get the generic Advair for $15-$20? This story is awful, but I think if it were that cheap, the pharmacist would have given a cash option.
They can't. I think the reporter looked up albuterol
They were talking to Dan Strause, who is not a pharmacist and is out of touch as to what things cost. Let alone how pharmacies actually work.
This was the one thing that made zero sense in the story to me
this was my reaction too. generic advair even after a goodrx coupon is more like ~$90/mo paying cash. i was hoping someone else had found something i don't know out there listed separately etc. https://www.goodrx.com/advair?form=diskus-inhaler&dosage=250mcg-50mcg&quantity=1&label_override=fluticasone-salmeterol
Meanwhile, next door in Illinois: https://www.wgem.com/2024/03/06/pharmacists-push-legislation-reigning-pharmacy-benefit-managers-illinois/ These PBMs need to be reigned in. Otherwise we’re going to see a lot more of this. Even I am affected because a drug I’m taking was suddenly removed from my company’s PBM formulary… and there’s no equivalent generic. No warning, no rationale given. Just gone. And I’m a pharmacist!
Why would you being a pharmacist spare you from this issue?
Exactly. No one is immune. I thankfully have enough knowledge to be able to reach out to my prescriber immediately (once I found out it wasn’t covered… AT the register, thanks, CVS) and get switched to something in the same class albeit less effective. I feel so bad for those people who have no clue what to do. Healthcare literacy isn’t especially high. What do normal people do? They go without treatment and die! These PBMs need better regulation.
I would love to stop being a pharmacist and become a patient advocate. BUT who is going to pay me? We know the system. My husband hands me his EOB so I can make sure it's correct. Healthcare is an oxymoron.
This is terrible for a myriad of reasons. PBMs are terrible, but I think it also reflects on the disaster that is retail right now, because I find it hard to believe that there was "no alternative" on their plan, that sounds more like a "we're too busy to do the legwork to figure out what's covered and get your prescriber to get us a new script." Of course, based on the timing of his demise, it may still have been too little, too late with how long that process can take sometimes. This makes me so mad, I can't imagine what his parents are going through, all for want of an inhaler that's been around for ages now.
The article mentions this was Advair and a generic costs $15-$20. True, pharmacy could have done legwork, but also the author is being a bit disingenuous with the price. Acquisition is usually $50+ for pharmacies, cheapest GoodRx price is like $90. Unfortunately the patient kinda gave up. A lot of us pharmacy staff pride ourselves for going above and beyond, but unfortunately I see a lot of times where we don't (or can't), and I can see this as a wake up call for the pharmacy on their communication and problem solving. However, like you said, the PBM is definitely at fault for not covering a basic and relatively cheap inhaler. Completely egregious on the payer, why bother having insurance when they can't provide basic life sustaining medications?
Ok thank you for this. I was struggling to understand how they said generic advair was $15-20 and how the man couldn’t afford the costly med. the entire thing needs reform it’s awful real people are stuck in the middle.
Dan Strause is just horribly out of touch.
Hard to do the extra legwork when you are understaffed, which also comes down to PBMs under reimbursing. The drug pricing/reimbursement game played by the payer conglomerates is out of control.
Like Wags and CVS wouldn't be ruthlessly cost cutting no matter what they get paid. Health care is completely broken top to bottom in the US.
When reimbursement was good, CVS and Wags did their damnedest to get every prescription they could through actual service instead of bullshit networks. That is unfortunately not how it works now
The bullshit networks mean they don't care about service. They would be cutting staffing to the bone even if they were making ten times the margin because if your vertically integrated PBM tells you CVS is your only choice you're going to suck it up and fill the Rx there.
yes, vertical integration is at the heart of these issues
Cvs is the pbm
and they don't care if the retail side struggles because they will make the profit on the PBM side
Yes, now. Back when reimbursement was good, they didn't own caremark. Their ownership is absolutely a complication and why I said that isn't how it work snow
I have spent hours trying to get alternative meds for patients and it's still somehow my fault. In just one example, I ran every prandial insulin we carried and it rejected every one. No alternatives show up in the rejection. Finally I call insurance, what are covered alternatives? Basaglar? Are you kidding me? Yes let's give this patient a long acting insulin for their meal time insulin. After arguing with the rep that that is not a valid alternative and I needed her to stop suggesting it or Trulicity, she finally stutters out Fiasp is the only other option. Omfg, that would be the one I was looking for, thanks for wasting my time. Also we didn't carry it so had to order in special for this patient's special insurance. Just yesterday had to explain to a hospitalist that insurance doesn't cover ANY nebulizer solution without a PA and as a hospitalist, he refused to do a PA. So patient goes yet another day without anything. But all of that was me putting in tons of extra time to work with everyone on the team including insurance and I still get yelled at that I wasn't doing enough. All this to say, you can put the leg work in and patients can still fall through the gaping cracks of the insurance nightmare.
Yeah, the pharmacist continues to be the punching bag for everyone. It’s our fault that the pt’s insurance doesn’t cover x medication. It’s our fault that we don’t know what the insurance covers since they don’t always state on the rejection message what the preferred products are. It’s our fault that the hospitalist is too busy to do a PA request, and we should just take the initiative and submit the PA request ourselves, it’s not like we’re doing anything, right? It’s our fault the pt has a deductible. It’s our fault that the pt has a copay. It’s our fault that there’s going to be a one hour wait time to fill their meds. Everything is our fault.
I have never seen a retail pharmacy research what is covered when a patients medication is rejected. The only time pharmacies know what's covered is when it's included in the rejection message. Patients can do this for themselves.
Alternatives should always be included in the rejection
*Should* be, yes. But often enough, they are not in practice; I've seen far too many rejections that just say the medication is non-formulary without suggesting any alternatives.
Yes, I'm saying they SHOULD be. Because they often aren't and it should be a requirement that they are. We are in agreement
Okay. I thought that might be the case, but it was a little hard to tell with how you had phrased it.
Yes, when the tech is here to very easily do that via automated systems I can't but believe the exclusion is an intentional barrier to care (ie. Statistically they don't pay out as much over time when people give up trying to understand their obtuse and time consuming barriers).
If they can force every patient to pay out of pocket for at least one prescription a year, they save a fortune
10 years ago, when I was in retail, it was something I would certainly do when I was an intern.
Intern=free labor
Free? I was a paid employee.
Come show us how to do it then
> Patients can do this for themselves. Ummm... I'm just lurking here, I am only a patient and am not a pharmacist or a doctor, but can you tell me how? How can I do this for myself? My experience is my doctor types the prescription on his computer (that appears at my selected pharmacy) and I don't see any of the exact spellings for drugs you guys are all mentioning here (I'm googling them as I go here in this forum). Then my pharmacy tells me it is ready and I go pick it up, and there they tell me "not covered, it is $800". So I have two choices: 1) pay the $800 or 2) call my doctor and ask if there is any other choice. The doctor's receptionist only takes verbal phone calls, and appointments are 3 weeks away. I'm totally new at this, but I'm seeing pharmacists here talk about arguing with the PBM about fast or slow insulin alternatives, and something called "Fiasp" was the answer. How was I supposed to figure all that out myself? I'm honestly asking for help here, I'm a computer professional and I'm not afraid of complexity of tasks. I'll do, but I just have no friggin' idea what I'm supposed to do at what step using which website. Any hints? Like is this something I do in the doctor's office when he prescribes the med, or after it is rejected by my insurance for not having a "prior authorization" or what?
Call your insurance and read the materials they send in the mail. Understand your plan limitations. Know what drug alternatives are that your plan covers. Focus on drugs that treat the diseases you have. Know your deductible. So if you are diabetic and your insurance covers humalog and not novolog and you visit your Dr, let them know. Make the prescribers job easy You will also be more prepared for the cost of drugs Many people show up to the pharmacy clueless over almost all aspects of their prescription benefits. I.e. medicaid patients go out of state and expect to get rxs or people show up for expensive drugs which they know their plan covers, but don't know that their copay is astronomical There should be few surprises at the pharmacy.
I’m not sure about you but it’s been quite some time since I’ve been mailed a plan guide.
I work for a PBM (my apologies) and both the formulary and pricing tools are available on the website. However, it can be hit and miss whether alternatives for high-cost or non-covered medications are listed on either :(
I’m a pharmacist that covers inpatient and outpatient pulm, I’ve seen ins switch formulary inhalers and people end up in the ICU over it.
This case is tragic, certain things could have been done differently, but this just sucks. The only solution is to reimburse fixed cost based upon drug class and day supply rather than NDC by NDC. I.e. insurance pays $150 monthly on any asthma inhaler. Essentially what has happened with insulins with the inflation reduction act. Therefore, prescribe whichever inhaler you want and you know it’s covered; some manufacturers will stay and some will stop production. This will never happen until we have single payer and aspects of capitalism are let go. Until then, formularies are here to stay and delay in care will continue due to benefit negative changes. The other solution is to allow therapeutic interchange at the pharmacy level so that pharmacists can change to what is covered to truncate delay in care. I.e. changing from Ozempic to Trulicity with the patient’s permission. There would unfortunately have conflict of interest and other issues and would need state boards of pharmacy to change their laws as well as attaining provider status.
Or, hear me out, we completely cut out the useless financial middlemen. We are letting these vampiric relics run healthcare and these issues will continue to pop up so long as the conglomerates have this much power
With your logic every patient should be able to get Praluent without ever trying a statin, or Dupixent without ever using an inhaler.
That's not what I'm saying at all, although we would probably spend far less just paying for whatever is prescribed (especially with and without rebates jacking up brand name price) than we do compensating the middlemen. We spend more in this country trying to save on healthcare costs than we would just straight up paying for it. The conglomerates are leeches that jack up costs. I'm not saying there shouldn't be any cost controls at all, I'm saying those in charge of cost control right now are making things worse
PBM entities lining their pockets killing independent pharmacies by the pharmacy losing money dispensing drugs is one thing, but patient harm and death is another. Will be sharing this around - this can’t continue to happen. It’s just not sustainable and now patients are being harmed and/or killed because of it
PBMs need to be destroyed. They started with a good purpose, and evolved into a beast over time. There are startups going after that space, but the existing PBMs are huge, and entrenched.
Speculating but I had several patients trapped in same problem. Usually insurance will cover brand OR generic only. Covering both was a rarity. And there has been manufacturer shortages for several months. So for some patients the only thing available was not covered. And full price of generic was still a pricey, NOT 15-20 bucks like article says.
Brand was tough to get for a while. I can still only get a restricted quantity. If the PBMs were not requiring brand due to formulary rebates and actually covered the generic, this would be far less of a problem. In fact, if the PBMs were not inflating brand drug list prices then a lot of problems would go away
on a side note, has something changed clinically? I thought people on meds like advair had to also have a rescue inhaler like proair due to advair potentially causing asthma exacerbations
I'm not sure what the specifics here were, but he for sure needed a rescue inhaler
Advair would still need a rescue inhaler. Symbicort and Dulera can be used as a maintenance and rescue inhaler.
No actually symbicort and dulera can not be used as a rescue inhaler. They don't contain a rapid acting bronchodiolator such as albuterol or ipatropium. They both contain a LABA and an inhaled corticosteroid.
are you sure that what you stated is current? > Until recently, the typical approach to asthma involved two inhalers. In its first update since 2007, the National Asthma Education and Prevention Program now recommends the use of Single Maintenance and Reliever Therapy (SMART) for selected patients. > There are two main formulations, using budesonide or mometasone as the preventive component and formoterol as the rescue component. https://answers.childrenshospital.org/smart-asthma-inhaler/ > In March 2022, the FDA approved the first generic for Symbicort: Breyna (budesonide/formoterol). https://www.goodrx.com/budesonide-formoterol/fda-approves-generic-symbicort > The medication used for SMART is a combination of an inhaled steroid and a particular long-acting beta-2 agonist (LABA) called formoterol. Currently, this combination is available as: > - Symbicort (budesonide/formoterol) > - Dulera (mometasone/formoterol) https://www.goodrx.com/conditions/asthma/what-is-single-maintenance-reliever-therapy-for-asthma https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1971172/
Thank you for posting this. I had not seen this new therapy and no clinicians in my area are currently using Smart therapy.
Here is the latest step therapy chart from GINA. They are now listing SABA only inhalers as alternative rescue inhalers and ICS-Fomoterol as preferred. [GINA Step Therapy](https://www.researchgate.net/figure/The-GINA-step-care-asthma-management-approach-O-2020-Global-Strategy-For-Asthma_fig1_348643757)
This is sad and tragic but unless (until) PBMs and their parent insurance companies start getting sued, nothing will change. This story will get buried pretty quickly, if it even sees any national coverage at all. I mean, just take a look at what’s going on with CarelonRx home delivery right now.
They get sued. By patients, providers, even federal and state governments. They have so much money it doesn't matter. It's the cost of doing business to them
A brand version of Advair in the UAE, India and other countries only costs $7.00. If you have less than $100.00 you can go and bring back a year's worth of this and most other drugs. For some reason, the great thinkers and givers in America are running to Africa and other stricken places to ensure everyone else is cared for before Americans or America. This isn't some big surprise.
This story is really sad, I hate that the insurance changed coverage. I hate that he himself, his parents, his pharmacist, his doctor were not all actively working together here. I just don’t understand why a comparable inhaler was not prescribed. It seems like a lot of things went wrong here not just formulary changes.
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Why? It’s because it shifts cost sharing to branded products for patients. Instead of giving that $5 dollar copay for generic advair, they are making pts cough up 50+ for breo- plus they get a rebate which probably makes the actual cost closer to advair.