Dodges by pharmacy benefit managers & an insane system keeping U.S. drug prices artificially high are the new normal. Here are ways patients can save some money.
I first met Ms. M in May of 2019, when she came in with a complaint of severe menopausal symptoms since her family doctor told her to stop her hormone therapy she had been taking for 20 years. She did, and was miserable within weeks, with drenching night sweats and hot flashes all day long! We needed a new plan because her risks of continued hormone therapy were outweighed when balanced against the benefit of a good night’s sleep.
Without going into the details, I prescribed a widely used form of an estradiol ‘patch’ that would deliver her enough hormone to keep her comfortable. What happened next is what burns me up – and this is now a daily-to-weekly occurrence in my practice! I’m going to describe the event and then the reality (in italics) to clue you in as to what is really going on between your doctor and your pharmacy.
Week 1: The dreaded pharmacy benefit manager (PBM)
Ms. M phones the office a week after the prescription was sent to the pharmacy to let me know that her pharmacy benefit manager (PBM) denied the prescription. She told the office that the letter she got in the mail yesterday (who uses mail anymore?) told her that: ‘specific details were not provided by your doctor to allow us to process this prescription’ and that ‘prior authorization was required’ for this particular medication.
Reality: PBM inserts a wedge of mistrust into our doctor-patient relationship.
I prescribed this medication as I prescribe all medications – with a specific, FDA-approved indication attached to it, as part of the electronic prescription process. The mumbo-jumbo about ‘details’ is a dodge used to delay filling the prescription and insert a wedge of mistrust into the doctor-patient relationship.
It implies that IF I had done my part correctly, the medication would have been in the patient’s hand already. This is not true. There is no way to know what ‘details’ this PBM requires, and they are free to change the ‘details’ at any time without notice because none of this information is readily available to the prescribing physician.
Week 2: Classic stall in filling Ms. M’s hormone therapy prescription
Ms. M inquires about the ‘prior authorization’ paperwork, which her letter from her insurer clearly indicates was sent to our office. We find a letter dated one day prior that indicates that a phone call and additional documentation is needed to justify this prescription. Alternative medications that should be considered and are ‘on formulary’ are provided, which include: Vagifem, Premarin cream and Estrace cream.
Reality: Delay in dispensing her medication, while eroding her trust in her doctor.
This is another dodge designed to consume as much time as possible between prescribing and dispensing. My prescription for Ms. M was for a transdermal estradiol patch that supplies estrogen through the skin to her entire body. The ‘suggested alternatives’ are all topical vaginal estrogen products, which have minimal and variable absorption into the blood stream. They are in no way appropriate for her.
Yet, again, this suggestion of alternatives further serves to erode trust, as Ms. M may be wondering why my prescribing habits are apparently ‘deviant’ from what is being suggested.
Week 3: PBM wants a peer-to-peer review, so bye-bye lunch break
The pre-authorization paperwork is sent in and indicates that the prescription is denied. The notice suggests that Ms. M be prescribed oral conjugated equine estrogens (what she had been taking for the past 20 years and which we discontinued for safety reasons), which is on formulary. If transdermal estradiol is still being requested, a ‘peer-to-peer’ review is required. This means that the physician must call the insurance company and go through a phone tree to connect to the appropriate person at the insurance company to have this conversation.
It also means that I must have at the ready the patient’s insurance identification number, her medical record number, date of birth and the specific claim number. If I am missing any one of these numbers, I cannot get through to have the necessary conversation. My typical peer-to-peer call takes between 10 minutes to up to 30 minutes: bye-bye lunch break.
Reality: The PBM really doesn’t want to pay for this drug!
They are going to delay as long as they possibly can and make it as personally painful and difficult for me, the prescriber, to get this medication to this patient.
Week 4: Approval – but the prescription drug price is too high for her!
Ms. M gets a letter. The medication is approved for one year. It will have to be re-evaluated again, using the same process, one year from now. When she goes to the pharmacy to pick it up, she is told that she will have to pay out of pocket $100 a month for the medication. She is not willing to pay this much and asks for an alternative.
Reality: Here we go again!
The U.S.’s prescription drug price problem, a hot-button voter issue
This is the new normal for many of my patients and it is disruptive to their health, our office and my life!
The United States spends about $325 billion on prescription drugs per year, according to the Hutchins Center. This is more than twice as much as other comparable nations such as Australia, Canada, France and the UK. This increased expenditure is not due to increased use of medication, it is all about cost.
Americans pay more for their prescriptions, and they tend to make higher-priced choices. One in four Americans report difficulty paying for their prescription medications. Compared to the per person spending on prescription drugs in 1980, the average American spends almost 10 times as much today, even after adjusting for inflation. It’s no wonder this is a hot-button issue for voters.
As a doctor who prescribes medication on a daily basis, I share these frustrations and find that I and my patients are being subjected to more and more scrutiny about the prescriptions that I write. The process is beginning to take on the form of harassment, as our fragmented healthcare system seems to be spinning out of control.
What you can do to reduce prescription medication costs and aggravation
It’s time to stop the insanity! Here are some of the things you can do as a patient to minimize aggravating delays in your treatment and unacceptable costs that will strain your budget or cause you to forego the medication entirely.
Get a reality check on what your medication may cost
- Goodrx.com is a helpful website that lists competitive prices for prescription drugs.
- Many medications also have short-term coupon programs for patients with private insurance for their medication (no Medicaid or Medicare), which can be helpful if you are deciding whether or not the new medication is better for you.
- Overall, though, coupons seem to be driving up the cost of medication, because they are usually provided for newer, more expensive brands that may not offer benefits for most.
Shop around for better prescription medication prices
Did you know that costs can differ from pharmacy to pharmacy? Costco and Sam’s Club often have less expensive prescriptions than your neighborhood pharmacy. Mail order outfits can also save you money.
Scrutinize your prescription plan
- Many health insurance carriers now outsource their medication management to pharmacy benefit managers, who contract directly with the drug manufacturer to purchase medications with bulk discounts.
- This means that – if your medication is NOT one purchased in bulk or is not even on the formulary of your PBM – you will be paying maximum cost, with out of pocket expenditures that sometimes exceed the typical retail cost of the drug!
- PBMs do not publicize their pricing arrangements, but it may be possible to switch to a more favorable prescription medication plan during your workplace’s open enrollment period.
Complain to your insurance company
If your prescription plan is working poorly for you, you should provide feedback to your health insurance carrier, as they may respond to multiple patient complaints by selecting a less restrictive medication plan or PBM.
Use your individual political clout to advocate for the candidates who you believe will work to restore sanity to this system!