The wacky games Pharmacies play

Not dead yet!

Well-Known Member
This was in the news yesterday:

------------- Excerpt:
(Definition: PBM - pharmacy benefit manager - the company name on your pharmacy benefit card)

The Hidden Monopolies That Raise Drug Prices
How pharmacy benefit managers morphed from processors to predators
David Dayen
March 28, 2017

Why haven’t PBMs fulfilled their promise as a cost inhibitor? The biggest reason experts cite is an information advantage in the complex pharmaceutical supply chain. At a hearing last year about the EpiPen, a simple shot to relieve symptoms of food allergies, Heather Bresch, CEO of EpiPen manufacturer Mylan, released a chart claiming that more than half of the list price for the product ($334 out of the $608 for a two-pack) goes to other participants—insurers, wholesalers, retailers, or the PBM. But when asked by Republican Representative Buddy Carter of Georgia, the only pharmacist in Congress, how much the PBM receives, Bresch replied, “I don’t specifically know the breakdown.” Carter nodded his head and said, “Nor do I and I’m the pharmacist. … That’s the problem, nobody knows.”

This lack of transparency enables PBMs to enjoy multiple hidden revenue streams from every other player. “It’s OK to have intermediaries, we have Visa,” says David Balto, an antitrust litigator and former top official with the Federal Trade Commission. “But these companies make a fabulous amount of money, even though they’re not buying the drug, not producing the drug, not putting themselves at risk.”

The PBM industry is rife with conflicts of interest and kickbacks. For example, PBMs secure rebates from drug companies as a condition of putting their products on the formulary, the list of reimbursable drugs for their network. However, they are under no obligation to disclose those rebates to health plans, or pass them along. Sometimes PBMs call them something other than rebates, using semantics to hold onto the cash. Health plans have no way to obtain drug-by-drug cost information to know if they’re getting the full discount.

On a personal note, this is why you can't get sudafed even if you DO have a prescription for it. When it became restricted, I tried with a prescription to get a month's worth and was unable. However I know it is manufactured because decades ago I was prescribed it and it worked fine. It was a blue and green capsule with little pellets inside, not the white caplets you get now. Many drugs are probably now OTC to avoid the PBM trap, even though they are "new" (example, Nexium).

It also leads to orphan drugs, that are described in medical journals, but can't be successfully prescribed because they are never stocked by anyone anymore. It's kind of like the reason why you have no control over what your supermarket carries, the distributor decides such things. By just ignoring a drug, they can effectively remove it from the market and doctors lose that tool.
You can get sudadfed in a pharmacy. You have to ask the pharmacist and the pharmacist will take your drivers license and put a number unto a databank. I was a pharmacist in community pharmacy for 23 years before becoming disabled from cfs.

There is a limit to how much you can buy due to people making meth from it. I am in NJ and just bought sudafed a few months ago at a cvs.

The drug prices fluctuate like crazy. I would get billed 800 dollars a bottle for something that was 20 dollars the month before.( this is wholesale! Then the ins wants to reimburse me for the 20 dollar rate! ) This was over 7 years ago . I could not believe this bs was legal. It is the manufacturer 's who gouge . They charge over 100 dollars for ingredients that were 5 dollars 5 years ago. No wonder the insurance companies don't want to pay. I can order medications from India ( I have for myself on occasion) that are totally fine and cost 90% less then in a us pharmacy. I can't believe this is legal. We need a department of consumer protection in this country.

Forum Tips

Support Our Work



Shopping on For HR

Latest Resources