1. Paying Pharmacies Below Their Cost to Buy Medications: This is not competition — it is market destruction.
There are dozens of examples daily at most every community retail pharmacy. These are some examples to showcase the commonality of items, with specific exact dollar values and what these medications are for. EVERY insurance plan is doing this to one or more medication, to most every pharmacy, on a regular basis. No other industry sells product […]
2. Self-Dealing Through PBM-Owned Mail-Order and Specialty Pharmacies: This is preferential treatment, not a free market.
*Patient fills and picks up 8 medications regularly through retail community pharmacy. After 2 fills of Humalog, is told now must use mail-order facility or pay 100% out-of-pocket for medication. Patient cannot get an override or authorization to keep refrigerated insulin therapy at local community pharmacy, is required to use Express Scripts mail order for […]
3. Non-Negotiable, Take-It-or-Leave-It Contracts: This imbalance of power removes real competition and violates fair dealing principles.
*Most pharmacies today exist with a relationship into what is known as a Pharmacy Services Administrative Organization, or PSAO, that helps “negotiate” contract terms with PBM’s. Most “negotiations” today exist as a review of what is given to the PSAO, and whether the PSAO feels members can financially sustain such a contract. Then, contracts are […]
4. Lack of Transparency and Data Access: Markets cannot function when pricing and rules are hidden.
*PBM’s are one of the few organizations that can be asked for information and tell such requestor to “take a hike” on a regular basis. *Rules continue to change with the PBM’s, continuing to add to the confusion and complexity in reviewing these plans and policies, as well as typically only benefiting the bottom-line of […]
5. Steering, Clawbacks, and Retroactive Fees: This creates financial instability by design.
*One large employer group underwrote a health insurance policy with prescription coverage for their 300+ employees. The employees found upon attempts to use the policy that the CareMark policy required them to either pay out-of-pocket or utilize a CVS/CareMark pharmacy (mail order, or nearly 100-mile average for employees to the nearest physical store). *PBM’s hold […]