Melanie Einbund
You thought filling a drug prescription was simple, but …
What is a PBM (Pharmacy Benefit Manager)? A PBM is a middleman between prescription drug benefits for health insurers and employers, negotiating drug prices, creating formularies, and processing pharmacy claims. Originally designed to protect and save money for health insurers and patients, recently, they have grown to exhibit monopolistic behaviors coupled with a lack of transparency. Frankly, they may be doing the exact opposite of their original intent.
Who is in control? Did you know that over 80% of all pharmacy benefits are controlled by three of these companies? Express Scripts, Caremark/CVS, and OptumRx. If these names are familiar to you, it is because they not only manage your pharmacy benefits but also own their own pharmacies that they may be forcing you to use. This is known as “Patient Steering.” Over the next year, we will be sharing your anonymous stories of how you are being affected every day while trying to manage your chronic diseases and health issues.
A Story: I went to my local pharmacy to pick up a refill on my medication for diabetes. It is normally $50 a month, but when I went to pick it up, it was $850. Nothing was different with my prescription. I didn’t understand. The pharmacist made some phone calls and found out that my mail order pharmacy could fill it for $50 for three months. I did not want my refrigerated medication mailed to me because of the heat and the fact that I still work and may not be home when it is delivered. I asked if I could still get it from my local pharmacy for the same price, and Tricare said I had to get it through Express Scripts mail order or pay the $850. Reluctantly, I transferred my prescription to mail. It took over two months to get my prescription, because Express Scripts said they did not have the medication. I still cannot believe that my medication was available at my local pharmacy! Because of the cost difference, I was forced to be without medication. I recently found out about PBMs, and to my dismay, I found out that Express Scripts is my PBM. They manage my Tricare plan. I cannot believe it, and as a veteran, I was treated this way!
There are solutions that Arizona legislators are currently working on to reign in these behaviors and allow for PBMs to only do the job that they were originally created for: protecting health insurers/employers and patients.
What you can do: File a complaint to your insurer, contact your local/state and federal legislators and tell them how you are being affected, submit a 60-second video through PUTT (Pharmacists for Truth and Transparency), sign up to vote on legislation, email PBMsgonewild@gmail.com with your anonymous stories for publication in this paper.
Come to our informational seminar on March 31 at 4 p.m. in the SaddleBrooke One Vistas dining room.