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 TriCare benefit. Missouri, 9/12/2025
*Medicare widow fills 11 prescriptions for diabetes, high blood pressure, cholesterol, and depression on a limited income but is able to afford with help from secondary insurance option through state assistance program. PBM CareMark recognizes fills at local community pharmacy and sends patient notifications to complete a paper form and send back signed to continue receiving medication, but through CVS/CareMark mail-order. Patient is confused with letter, brings to pharmacy to inquire, and is angered that the paper is misleading, attempting to get patient to send medications to mail-order pharmacy instead of using local retail pharmacy option. Missouri, 2/8/2025
*Patient is reviewing prescription benefits for Medicare options during open enrollment. Finds cheapest overall plan is WellCare Medicare Part D plan at choice community retail pharmacy. Insurance broker signs patient up for this plan, and upon filling prescriptions receives a letter in the mail from WellCare stating if patient would utilize CVS/CareMark store 30 minutes away then patient would not pay copayments for her 4 medications. Patient is angered to be bothered by insurance to switch pharmacies, to a point patient threatens to drop insurance policy and pay out-of-pocket until community pharmacist advise potential of non-insured penalty that could accrue the remainder of patient life. Missouri, 1/18/2026
*Patient fills prescriptions at local retail pharmacy for 30-day prescription. Ten days later, a 90-day prescription arrives in the mail from Centerwell pharmacy for the same exact medication. Patient states to never have authorized that fill, finds it is filled 2 days after filling of local retail pharmacy, and is confused and angered was not given any option into where to have prescription filled. Missouri, 12/24/2025
*Widow stops into local retail pharmacy asking if staff knows of any patient(s) needing specific medications or where those medications could be donated. Widow is asking because spouse passed away nearly 6 months earlier, and every 2 months the widow continues to receive 90-day refills of patient medication. Says Humana explanation of benefits (EOB) shows each 90-day fill is over $1,000 paid to CenterWell pharmacy, and widow cannot stand to see that much medication simply destroyed because of fraud and waste. Retail pharmacy unfortunately informs patient they are unable to repurpose any medication to patients it is not prescribed & labeled for use. Missouri, 6/25/2025