Walmart Wrestles With Reality of Preferred Networks

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BF7 said:
Broke my examples?
What planet do you live on?


Pharmacy reimbursement is dictated by AWP-a percentage ( plus a minuscule dispense fee) or MAC'd out.

I could submit $1,000,000 per tablet of atenolol 100mg #30 and guess what? I get paid the PBM MAC'd rate of $1.82

A pharmacy's U&C is as worthless of a number as AWP. You don't know what you don't know.
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Can you answer the direct question please? You are still avoiding it.

Pharmacy reimbursement (when using a PBM) is dictacted by various different terms but that's all conditioned on the fact that you accepted those terms.

And if we are talking about walmarts sh*tstorm they are in... U&C is actually not useless when its below the PBM MAC'd rate like their cheap generic program. You should know that.
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PharFromNormal said:
Can you answer the direct question please? You are still avoiding it.

Pharmacy reimbursement (when using a PBM) is dictacted by various different terms but that's all conditioned on the fact that you accepted those terms.

And if we are talking about walmarts sh*tstorm they are in... U&C is actually not useless when its below the PBM MAC'd rate like their cheap generic program. You should know that.
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And why does a pharmacy accept those terms?

U&C is worthless. The only thing you've gotten correct is that Walmart $4 strategy backfired on them and has brought our industry down with them.
 
BF7 said:
PBMs dictate the market.

And with more patients than ever having insurance they are coming closer to dictating 100% of the market. See the 1st post article in this very thread.

If a typical community pharmacy wants to you know, PRACTICE PHARMACY, they HAVE to deal with PBMS.

Your inability to grasp this concept is what's distorting your whole misguided perspective
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Again technically incorrect. While yes I strongly suggest contracting with PBMs to run a successful business it is not mandated by any legislation that you must. If one was to operate with a complete out of the box business model or dispense medications for free (maybe with state funding or donations at a free clinic perhaps?) they could. Your inability to grasp that I am sticking to pure facts and not inferences or suggestions is what is preventing you from missing the whole reason I continue to respond.
 
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BF7 said:
And why does a pharmacy accept those terms?

U&C is worthless. The only thing you've gotten correct is that Walmart $4 strategy backfired on them and has brought our industry down with them.
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All please witness BF7 continue to not answer the question again.

Does a PBM set your U&C?
 
PharFromNormal said:
Again technically incorrect. While yes I strongly suggest contracting with PBMs to run a successful business it is not mandated by any legislation that you must. If one was to operate with a complete out of the box business model or dispense medications for free (maybe with state funding or donations at a free clinic perhaps?) they could. Your inability to grasp that I am sticking to pure facts and not inferences or suggestions is what is preventing you from missing the whole reason I continue to respond.
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What color is the sky on your planet?
 
BF7 said:
This was explained to you previously.
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All bear witness. The very basic and straightforward question posed 3 different times cannot be answered with a yes or no answer by the wise BF7.
 
BF7 said:
What color is the sky on your planet?
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Where am I, what's the weather, and what time of day is it? Some see blue, some see black, some see great variety at the sunrise and sunset. Currently where I am the night sky looks like a blackish purple due to the lights in the area.
 
PharFromNormal said:
Again technically incorrect. While yes I strongly suggest contracting with PBMs to run a successful business it is not mandated by any legislation that you must. If one was to operate with a complete out of the box business model or dispense medications for free (maybe with state funding or donations at a free clinic perhaps?) they could. Your inability to grasp that I am sticking to pure facts and not inferences or suggestions is what is preventing you from missing the whole reason I continue to respond.
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I don't think anybody here has trouble understanding what you're selling. You're personally connected to a PBM. Good for you. At this point with 95% of the pharmacy market being controlled by PBM's, you have no choice but to do business with the PBMs. This is true even for the larger chains.

Where you are dead wrong is that you compare the PROFESSION of pharmacy to other businesses. Pharmacists go to school for at least 6 years. We carry all LIABILITY for filling these prescriptions. Even for prescriptions where the pharmacy makes only 1.50 or loses money, we carry equal liablity. The PBMs contribute NOTHING. They see no patients. They make no medications. They dispense no medications (unless patients are forced to use their mail order against their conscious will). Only in the convoluted health care system of the United States are they even a factor.
 
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southpharmindy said:
I don't think anybody here has trouble understanding what you're selling. You're personally connected to a PBM. Good for you. At this point with 95% of the pharmacy market being controlled by PBM's, you have no choice but to do business with the PBMs. This is true even for the larger chains.

Where you are dead wrong is that you compare the PROFESSION of pharmacy to other businesses. Pharmacists go to school for at least 6 years. We carry all LIABILITY for filling these prescriptions. Even for prescriptions where the pharmacy makes only 1.50 or loses money, we carry equal liablity. The PBMs contribute NOTHING. They see no patients. They make no medications. They dispense no medications (unless patients are forced to use their mail order against their conscious will). Only in the convoluted health care system of the United States are they even a factor.
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While I also understand what you're selling, you also need to understand that receiving revenue for what we do is essential to our profession or else it will no longer be a profession. You cannot say that PBMs don't contribute in how a pharmacy receives revenue. Everyone hates "the man." I get it. If you think pharmacists are the only ones experiencing this though you're wrong. I can compare this to other professions. Let's take a doctor who owns their own private practice or a dentist who has their practice. Both provide direct care, both recieve the significant amount of their revenue from a third party. Both have liability and both actually can lose money on certain patients and certain procedures. Again I won't argue that our health system is convoluted. I'll be the first to stand up and agree on that one. And again in order to do business in this convulated system you need to figure it out, pass legislation or get out.
 
PharFromNormal said:
While I also understand what you're selling, you also need to understand that receiving revenue for what we do is essential to our profession or else it will no longer be a profession. You cannot say that PBMs don't contribute in how a pharmacy receives revenue. Everyone hates "the man." I get it. If you think pharmacists are the only ones experiencing this though you're wrong. I can compare this to other professions. Let's take a doctor who owns their own private practice or a dentist who has their practice. Both provide direct care, both recieve the significant amount of their revenue from a third party. Both have liability and both actually can lose money on certain patients and certain procedures. Again I won't argue that our health system is convoluted. I'll be the first to stand up and agree on that one. And again in order to do business in this convulated system you need to figure it out, pass legislation or get out.
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And while BF7 continues to avoid the direct question (I'll ask again: do PBMs set your U&C?) I'll provide my recommendation to anyone (indy or not). In this current fragmented system that is increasingly more cost conscience, fighting to get paid more money for anything is likely a losing battle. From Reimbursment rates to the pie in the sky MTM (which I'm glad everyone here seems smart enough to understand is laughable already) it will continue to get harder and harder on all stakeholders in the convulated system. The mergers vertical and horizontal across the providers, suppliers, and payers will continue. Again, figure it out, pass legislation or get out.
 
BF7 said:
Can pharmacies, like physicians and dentists, commonly perform zero balance billing without being in violation of their one sided business decrees that your employer cleverly calls contracts?
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I'm sorry have you answered my question yet?
 
BF7 said:
PBMs dictate the market.
( and yes they DO dictate who a pharmacy can dispense too; caremarks maintenance program whereby patients HAVE TO go to a CVS or their mail order operation is a prime example)

And with more patients than ever having insurance they are coming closer to dictating 100% of the market. See the 1st post article in this very thread.

If a typical community pharmacy wants to you know, PRACTICE PHARMACY, they HAVE to deal with PBMS.

Your inability to grasp this concept is what's distorting your whole misguided perspective
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PharFromNormal is trying to pull a "gotcha" on the fact that they don't HAVE TO use CVS, it's just that they will pay the full U&C price if they go to any store that isn't a CVS. Yes, he is correct there. It's not mandatory for the patient, but it may as well be. Nobody is going to pay $75 U&C when they could get it somewhere for a $5 copay.

I suppose his argument about asking "do they they set U&C" is then implying "You should set your U&C so low that patients can ignore their PBM's coercive tactics and fill at your store for the same price they would fill elsewhere." Of course, this means that you'll be losing tons of money.
 
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PharFromNormal said:
And while BF7 continues to avoid the direct question (I'll ask again: do PBMs set your U&C?) I'll provide my recommendation to anyone (indy or not). In this current fragmented system that is increasingly more cost conscience, fighting to get paid more money for anything is likely a losing battle. From Reimbursment rates to the pie in the sky MTM (which I'm glad everyone here seems smart enough to understand is laughable already) it will continue to get harder and harder on all stakeholders in the convulated system. The mergers vertical and horizontal across the providers, suppliers, and payers will continue. Again, figure it out, pass legislation or get out.
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It was already explained to you why U&C plays little to no role when I fill Rxs for patients with insurance.

See the atenolol example I gave above.

Everyday that you clock in to work you are complicit in the demise of the profession that you went to school for while Sacrificing 5 -6 years of tuition, effort and time.

It's been explained to you clearly in this thread and others how your employers exploit our product and skills for their own profit.

The fact that you 1) haven't worked to find another avenue of pharmacy practice to make a living in and even worse 2) continue to espouse some imaginary virtue of a PBMs role in our healthcare system speaks to your poor moral character.

You are actively participating in the process of causing your chosen profession's demise...it would be ironic if your position was "vertically integrated" into extinction
 
BF7 said:
It was already explained to you why U&C plays little to no role when I fill Rxs for patients with insurance.

See the atenolol example I gave above.

Everyday that you clock in to work you are complicit in the demise of the profession that you went to school for while Sacrificing 5 -6 years of tuition, effort and time.

It's been explained to you clearly in this thread and others how your employers exploit our product and skills for their own profit.

The fact that you 1) haven't worked to find another avenue of pharmacy practice to make a living in and even worse 2) continue to espouse some imaginary virtue of a PBMs role in our healthcare system speaks to your poor moral character.

You are actuvely participating in the process of causing your chosen profession's demise....
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You stated I was correct about Walmart and also say U&C is as worthless as AWP which you also said is used in reimbursement (AWP - % + dispensing fee). Make up your mind and also answer the question!

Also for the record I do not work for a PBM. But I already forsee you trying to engage in a character fight about what I do or who I work for instead of focusing on the conversation and the question you refuse to answer. If it's so pointless then why don't you just answer it to get it out of the way?
 
Oh and it looks like you must have deleted your zero balance billing question after you realized that zero balance billing is more often than not illegal. So I guess I don't have to address that one.
 
Ackj said:
PharFromNormal is trying to pull a "gotcha" on the fact that they don't HAVE TO use CVS, it's just that they will pay the full U&C price if they go to any store that isn't a CVS. Yes, he is correct there. It's not mandatory for the patient, but it may as well be. Nobody is going to pay $75 U&C when they could get it somewhere for a $5 copay.

I suppose his argument about asking "do they they set U&C" is then implying "You should set your U&C so low that patients can ignore their PBM's coercive tactics and fill at your store for the same price they would fill elsewhere." Of course, this means that you'll be losing tons of money.
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Of course. I agree with you.

But It's a completely hollow argument as the insurer is able to pass a large portion of the price of the medication to the patient's employer. ( and get manufacturer rebates)

As a general rule, Individual pharmacies cannot bill employers for the difference between a copay and the total price charged.
So he's being intellectually dishonest too.

PharFromNormal said:
You stated I was correct about Walmart and also say U&C is as worthless as AWP which you also said is used in reimbursement (AWP - % + dispensing fee). Make up your mind and also answer the question!

Also for the record I do not work for a PBM. But I already forsee you trying to engage in a character fight about what I do or who I work for instead of focusing on the conversation and the question you refuse to answer. If it's so pointless then why don't you just answer it to get it out of the way?
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You're a health plan employee.

PBMs control the access to ~95% of patients in America today with their market share increasing.

Do PBMs set the prices that a pharmacy can charge for medications for 100% of that PBM's patients?

Answer the question.
 
BF7 said:
Of course.

But It's a completely hollow argument as the insurer is able to pass a large portion of the price of the medication to the patient's employer.

As a general rule, Individual pharmacies cannot bill employers for the difference between a copay and the total price charged.



You're a health plan employee.

PBMs control the access to ~95% of patients in America today with their market share increasing.

Do PBMs set the prices that a pharmacy can charge for medications for 100% of that PBM's patients?

Answer the question.
Click to expand...

Not a health plan employee. Continue trying to find out who I work for so you can try and poke the bear the right way.

Answer my question and I'll answer yours.
 
PharFromNormal said:
Not a health plan employee. Continue trying to find out who I work for so you can try and poke the bear the right way.

Answer my question and I'll answer yours.
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Your question was answered about U &C.

Now answer a legitimate question. Mine, which speaks the the essence of the issue at hand.


PBMs control the access to ~95% of patients in America today with their market share increasing.

Do PBMs set the prices that a pharmacy can charge for medications for 100% of that PBM's patients?
 
Fine even though you, yourself won't directly answer me. I will continue to directly engage on your questions.

No a PBM does not dictacte how much you charge. I think you are smart enough to understand the differences between amounts charged and amounts reimbursed because you referenced it earlier. I can charge you right now $1 million but that doesn't entitle me to anything. You recieve the amount based on the rates and conditions you agreed upon in your or your PSAO's networking contract. Oh and by the way patients do not need to use their PBM to recieve prescriptions from you. They can opt to pay U&C even if you have a relationship with their PBM.

Answer to question 2... It doesn't cost $12. I think I'm reading between the lines but this goes back to point 1. The amount charged does not equal the cost. I mean I guess if you work in the worst hospital ever and you are buying aspirin for that much but I highly doubt that...
 
PharFromNormal said:
Fine even though you, yourself won't directly answer me. I will continue to directly engage on your questions.

No a PBM does not dictacte how much you charge. I think you are smart enough to understand the differences between amounts charged and amounts reimbursed because you referenced it earlier. I can charge you right now $1 million but that doesn't entitle me to anything. You recieve the amount based on the rates and conditions you agreed upon in your or your PSAO's networking contract. Oh and by the way patients do not need to use their PBM to recieve prescriptions from you. They can opt to pay U&C even if you have a relationship with their PBM.

Answer to question 2... It doesn't cost $12. I think I'm reading between the lines but this goes back to point 1. The amount charged does not equal the cost. I mean I guess if you work in the worst hospital ever and you are buying aspirin for that much but I highly doubt that...
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You're right... It's more like $25.

http://www.healthcarefinancenews.com/blog/why-aspirin-taken-hospital-can-cost-upwards-25
 
PharFromNormal said:
Fine even though you, yourself won't directly answer me. I will continue to directly engage on your questions.

No a PBM does not dictacte how much you charge. I think you are smart enough to understand the differences between amounts charged and amounts reimbursed because you referenced it earlier. I can charge you right now $1 million but that doesn't entitle me to anything. You recieve the amount based on the rates and conditions you agreed upon in your or your PSAO's networking contract. Oh and by the way patients do not need to use their PBM to recieve prescriptions from you. They can opt to pay U&C even if you have a relationship with their PBM.

.
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Let's use your premise of a patient opting to pay U&C .


Say My U& C for nexium 40mg was $249

And The total price set by the PBM after AWP MINUS A % is $250.


By paying my U&C they'd be out of pocket $249.

With their insurance their copay isv$50 while the employer is billed $200 plus an " administrative fee" ( and the PBM likely gets a kickback rebate from the manufacture but I digress) .

In that example, the total price paid is more ( by a dollar) but the patient is incentivized to use their insurance because that way their employer pays 80% of the cost versus them paying 100% of the U&C.

Pharmacies have no relationship or legal modality to bill the employer for the difference between the copay ( whatever that may be)and the total price so they are forced to charge the patient 100% of the cost.
 
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But it's pointless to use the example above bc as you know, whatever I set my U&C at, the PBMs would ultimately work to decrease the total reimbursement beneath that.

It's the same reason why that single tablet of 81mg ASA in the ER is $25. Insurance companies actually INCREASE the cost of healthcare.

If my U&C was a penny the PBM contracted rate would be ZERO. Hospitals, pharmacies and physicians have to artificially increase prices in order to keep their lights on and doors open because of this basic premise.

Again, 99% of pharmacy claims are paid at AWP MINUS, WAC + or MAC values. Pbms paying on U&C is a very rare event because of the reason I stated above.

In summary, U&C is WORTHLESS as I stated previously.

Now answer this:

PBMs control the access to ~95% of patients in America today with their market share increasing.

Do PBMs set the prices that a pharmacy gets reimbursed( fixed it) for medications for 100% of that PBM's patients?
 
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You are a "Benedict Arnold" to our profession.

You're actively participating in the demise of your ( and my) chosen profession.

I'll repost this so maybe it sinks in this time:

You're just about hopeless.......here goes nothing.

A1 ) I own my rental property

A2) Pharmacies own the medications that they dispense to patients

B1) I set my own rental rates dictated solely by ME as the owner of that property; the property management agency does not.

B2) PBMs set the price that Pharmacies are reimbursed for dispensing product that the PHARMACY OWNS.

C1) I can offer my rental property to anyone who wants to rent from me (because of my great product or service) at the SAME PRICE FOR EVERYONE with no limitations placed on me by the management agency.

C2) Pharmacies are forced to charge patients a PRE-determined copay that may be different from Pharmacy to Pharmacy( if they even have access to that patient life at all.) that is dictated solely by the PBM.

The diabolical role of the PBM doesn't get contrasted any clearer than above against what a true free market would look like. In a free market, pharmacies would be free to compete for patients instead of access to patient lives being negotiated at the broker level with collusion between large corporate interests ( PBMs and chains preferred networks) and PBMs driving patients to pharmacies that they have a financial stake in for " specialty" medications and traditional maintenance meds...

I could go on but I've likely already covered the unscrupulous PBM practice in a previous post.
 
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PharFromNormal said:
And while BF7 continues to avoid the direct question (I'll ask again: do PBMs set your U&C?) I'll provide my recommendation to anyone (indy or not). In this current fragmented system that is increasingly more cost conscience, fighting to get paid more money for anything is likely a losing battle. From Reimbursment rates to the pie in the sky MTM (which I'm glad everyone here seems smart enough to understand is laughable already) it will continue to get harder and harder on all stakeholders in the convulated system. The mergers vertical and horizontal across the providers, suppliers, and payers will continue. Again, figure it out, pass legislation or get out.
Click to expand...

I'll play. No the PBM does not set my usual and customary charge. What does this have to do with the price of tea in China or anything else we're discussing?

I 100% agree that legislatively is the only way we have a chance of surviving. The legislative actions nationwide are starting to gain support and pass.
 
The health care system in our country has to change for everyone, patients and providers. The PBM model is the problem and needs to be eliminated.
 
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From the, it can only get worse department.......

Just a few days ago CVS/ Careless announced that they will now CHARGE PHARMACIES 0.15 Cents for calling the CVS/Careless Pharmacy help desk. It's only 15 cents though right Pharfromnormal?




"Providers will be charged for either a Transaction Fee (as described in the Transaction Fees subsection" or a Transaction Submission Resolution Management Service Fee, but not both for the same transaction."


It also says: "The maximum overall transaction submission resolution management service fee charged will be $0.15/ claim..."
 
BF7 said:
From the, it can only get worse department.......

Just a few days ago CVS/ Careless announced that they will now CHARGE PHARMACIES 0.15 Cents for calling the CVS/Careless Pharmacy help desk. It's only 15 cents though right Pharfromnormal?




"Providers will be charged for either a Transaction Fee (as described in the Transaction Fees subsection" or a Transaction Submission Resolution Management Service Fee, but not both for the same transaction."


It also says: "The maximum overall transaction submission resolution management service fee charged will be $0.15/ claim..."
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No big deal. Those fees are illegal in Texas.
 
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BenJammin said:
No big deal. Those fees are illegal in Texas.
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The transaction fees were deemed illegal but is the fee deemed " resolution management service fee" also included on the list of fees that cannot be billed to providers here in Texas? Or are they trying to get a fee through on a technicality?
 
PharFromNormal said:
A pharmacy can charge a patient whatever they want. IF a pharmacy wants to charge a copay/co insurance associated with that patients PBM, then they agree to a reimbursement as agreed upon with that PBM. It's not rocket science.
You are not mandated to accept any PBMs. You are well within your rights to operate as a cash only business.
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This is the most ridiculous rebuttal in the entire thread.
 
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BF7 said:
From the, it can only get worse department.......

Just a few days ago CVS/ Careless announced that they will now CHARGE PHARMACIES 0.15 Cents for calling the CVS/Careless Pharmacy help desk. It's only 15 cents though right Pharfromnormal?




"Providers will be charged for either a Transaction Fee (as described in the Transaction Fees subsection" or a Transaction Submission Resolution Management Service Fee, but not both for the same transaction."


It also says: "The maximum overall transaction submission resolution management service fee charged will be $0.15/ claim..."
Click to expand...

Do you have a link to that?
 
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It's time to just straight up run fake claims and take back all the money CVS Caremark is stealing from pharmacies. How can they get away with this? They have record profits year after year. Retail pharmacy is something else. We need to get rid of the PBM model. It is destroying health care in America.

So CVS Caremark will reject a claim and if I need to call to get an override, I will get charged for it? F*** CVS.

No, I'm not running fake claims, but something has got to give. What to do? Fight and let capitalism run the show, and all us little guys get swallowed up by the big guys? They have money to prolong our lawsuits for years and years. Or do we get government to step in and control everything? I don't know.
 
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CVS CARELESS is absolutely the modern day mafia....
 
farmadiazepine said:
It's time to just straight up run fake claims and take back all the money CVS Caremark is stealing from pharmacies. How can they get away with this? They have record profits year after year. Retail pharmacy is something else. We need to get rid of the PBM model. It is destroying health care in America.

So CVS Caremark will reject a claim and if I need to call to get an override, I will get charged for it? F*** CVS.

No, I'm not running fake claims, but something has got to give. What to do? Fight and let capitalism run the show, and all us little guys get swallowed up by the big guys? They have money to prolong our lawsuits for years and years. Or do we get government to step in and control everything? I don't know.
Click to expand...

This is a direct response to states like Texas that have banned PBM's from charging a transaction fee based solely on the adjudication of a pharmacy claim. Read the fax carefully...it's a fee tacked onto every single claim based on your monthly usage of resolution services. You will either get hit with a $0.15 transaction fee on every claim or a Transaction Submission Management Resolution Fee on every single claim.
 
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BF7 said:
From the, it can only get worse department.......

Just a few days ago CVS/ Careless announced that they will now CHARGE PHARMACIES 0.15 Cents for calling the CVS/Careless Pharmacy help desk. It's only 15 cents though right Pharfromnormal?




"Providers will be charged for either a Transaction Fee (as described in the Transaction Fees subsection" or a Transaction Submission Resolution Management Service Fee, but not both for the same transaction."


It also says: "The maximum overall transaction submission resolution management service fee charged will be $0.15/ claim..."
Click to expand...
Hmmm... Sounds like an opportunity. It's time to start charging patients $1 to call their insurance.
 
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