|HOMEABOUT US CONSUMERS MEDICAL PROVIDERS MEDIA HEALTH LINKS CONTACT US|
| WHO's MINDING THE DRUG STORE?
By Ardyth J. Eisenberg
When costs go up-up-up, fast-fast-fast, you look for ways to fix the cause. Gas prices have shown us this. Prescription drug prices are doing this, too. People and programs that pay for prescriptions are scrambling to contain prescription costs. This article looks at the size of the problem, what payers are doing in response, and how this affects patients.1
The size of the problem
Prescription drugs cost almost $300 billion a year, or 15 percent, of US health care costs.2 For private insurance companies, prescription drugs make up almost half their claims costs.3 Already in this century, spending on prescription drugs has gone up faster than spending on hospital or physician services.4 Several studies predict drug costs will increase six to nine percent in 2010 alone.5
What’s being done about it
Three-fourths of people who have insurance benefits for drugs have a PBM, whether they know it or not. Medicaid is required by law to use PBMs. Medicare Part D prescription plans may also use them. How the PBM does its job can have a direct effect on your medical care, just when you need it most. Here’s how PBMs work, with some pros and cons drawn from my personal experience.
You ask your drugstore to fill a new or an existing prescription. Your drugstore contacts your insurance company or the PBM for payment approval. The PBM steps in at this point to see whether it can save money on the prescription. Some insurance companies have their own PBM department. Others use independent PBMs services. PBMs ask these basic questions:
Is the drug appropriate for your condition? The PBM might screen for drug allergies that you have, point out dangerous interactions with other drugs you take or identify a similar, but less expensive drug than the doctor prescribed.6
The PBM may also see if the drug you want is on your insurance company’s formulary. A formulary is a list of drugs that your insurer, HMO or government program will pay for. (The PBM probably helped make the formulary list for your program, too.) If your drug isn’t on the formulary, it won’t be covered.7
The PBM usually looks to see if the drug you need is available in generic form, rather than brand name, which often costs less.8 The PBM may also suggest that you start with a generic or less expensive drug and switch to a brand name drug only if the first drug doesn’t work for you (called a “step program”).9
Finally, PBMs may use their purchasing power to negotiate discounts with drug makers, and pass some of that savings on to your health plan.
How this works, in general
Here is where things can get sticky, from your standpoint: If the PBM finds a way to save on your drug cost, it notifies the drug store or your physician and asks that the prescription be changed to meet its guidelines.
The drug you need is a form of medical treatment, just like visiting a doctor or hospital. The PBM’s recommendation can delay your medical treatment while it waits to discuss its request with your pharmacy and/or your physician. Sometimes the PBM may simply tell the pharmacy it won’t pay for the prescription, leaving the pharmacist to negotiate with your doctor and notify you. Either way, your doctor may not take kindly to having his or her decision second-guessed by strangers.10 And, either way, you’re in limbo, waiting for medical care your doctor recommended, while the conversation goes on with the PBM. The worst part of this process is that you are forced to wait for medical care that you need at the worst possible time – when you need the care.
How this works, in particular
A woman who has serious arthritis takes medication once a month for the disease. Her insurance company’s case management department coordinates the care for her. Despite that, her insurance company’s PBM department stopped approving payment for the drug. She had to go without treatment while she tried to get the two departments to agree to resume payment.
An employer began using a new insurance company that had a PBM unit. The PBM denied a prescription drug that one member had taken for years, which the previous insurance company had always paid for. The PBM refused to pay, saying an over-the-counter medication should work as well. The member ran out of the prescription while she tried to show that the over-the-counter medication had long ago stopped working for her.
A PBM recommended “step therapy” for a woman who had taken the same antidepressant for several years. It denied payment for the antidepressant, without consulting her previous claims to see that other antidepressants had been tried, but did not work for her symptoms. She began experiencing withdrawal from the antidepressant before the PBM finally approved payment.
A PBM refused to pay for a higher dosage of a prescription drug, saying the new dosage didn’t exist, although it was listed in the PBM’s own formulary.
In all of these real-life cases, the patient, while needing medication, also had the burden of making certain that the PBM, pharmacy, insurance company and doctor talked to each other, and talked promptly. Here are some steps to take to ease the challenge.
What to do
|About Save the Patient Contact Us Health Resources/Links Make a Donation
Copyright © 2017 Save The Patient. All Rights Reserved.