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Is it possible for a BOP to create laws or regulations that prohibit insurance companies from steering "specialty" medications or high cost medications to only "specialty" pharmacies or PBM owned pharmacies?
Specialty medications were originally drugs which were used in special cases, usually as a second line, or third line, or fourth line drug, in special situations or special diseases. Drugs which are considered specialty now are not really special except for the fact they are high priced, and are the most profitable prescriptions. These drugs like new oral oncology drugs, new hepatitis C cures, HIV drugs are first line drugs and are the current standards of care. I know doctors cannot steer prescriptions to certain pharmacies, but how come there are no laws or regulations that prevent PBMs from steering prescriptions to their own in-house pharmacies? The prescriptions being steered are the most profitable prescriptions as well.
So what do you all think? Do you think if someone can make enough noise to a BOP, that it would be possible to create laws or regulations that would prevent insurance companies from dictating which prescriptions a patient can get filled or not filled and where?
This all stems from my recent issue of not dispensing Harvoni when I was able to obtain the drug, do all the clinical work for a PA, and not get reimbursed enough. This also stems from me filling HIV medications for hundreds of patients and then next month the patient is forced to go fill at a specialty mail order with no justification at all except that their HIV drug is now considered a specialty medication.
These barriers to medication access can be harmful to patients. The HIV patients who I have who are forced to fill somewhere else wind up missing days of medication even when I fight for overrides and get denied and even when they tell insurance companies that they don't have regular access to mail.
At the end of the day, it is not about making money, but it is about 2 things. The first is we have to keep independent pharmacies alive. We serve our community, and we know the people we serve. We are a community pharmacy for the community. We are not a remote location that communicates with patients through shipping labels and 1-800 numbers. The second, but more important, is the patient. The patients are the ones who suffer. The PBMs are creating barriers to medication access. The ease of access is not easy at all. The face to face communication between pharmacist and patient does not exist anymore. There is potential for medication interaction and harm when patients are filling drugs at multiple pharmacies. A patient who gets Gleevec at Cigna Specialty will go into CVS and be offered Zostavax? It happens.
Thoughts? I will keep you all updated on how far I get with this. I'm gonna try and make some noise in NJ. I want to make NJ a state where PBMs are not allowed to designate drugs as specialty and not allowed to steer these prescriptions to their own pharmacies.
Specialty medications were originally drugs which were used in special cases, usually as a second line, or third line, or fourth line drug, in special situations or special diseases. Drugs which are considered specialty now are not really special except for the fact they are high priced, and are the most profitable prescriptions. These drugs like new oral oncology drugs, new hepatitis C cures, HIV drugs are first line drugs and are the current standards of care. I know doctors cannot steer prescriptions to certain pharmacies, but how come there are no laws or regulations that prevent PBMs from steering prescriptions to their own in-house pharmacies? The prescriptions being steered are the most profitable prescriptions as well.
So what do you all think? Do you think if someone can make enough noise to a BOP, that it would be possible to create laws or regulations that would prevent insurance companies from dictating which prescriptions a patient can get filled or not filled and where?
This all stems from my recent issue of not dispensing Harvoni when I was able to obtain the drug, do all the clinical work for a PA, and not get reimbursed enough. This also stems from me filling HIV medications for hundreds of patients and then next month the patient is forced to go fill at a specialty mail order with no justification at all except that their HIV drug is now considered a specialty medication.
These barriers to medication access can be harmful to patients. The HIV patients who I have who are forced to fill somewhere else wind up missing days of medication even when I fight for overrides and get denied and even when they tell insurance companies that they don't have regular access to mail.
At the end of the day, it is not about making money, but it is about 2 things. The first is we have to keep independent pharmacies alive. We serve our community, and we know the people we serve. We are a community pharmacy for the community. We are not a remote location that communicates with patients through shipping labels and 1-800 numbers. The second, but more important, is the patient. The patients are the ones who suffer. The PBMs are creating barriers to medication access. The ease of access is not easy at all. The face to face communication between pharmacist and patient does not exist anymore. There is potential for medication interaction and harm when patients are filling drugs at multiple pharmacies. A patient who gets Gleevec at Cigna Specialty will go into CVS and be offered Zostavax? It happens.
Thoughts? I will keep you all updated on how far I get with this. I'm gonna try and make some noise in NJ. I want to make NJ a state where PBMs are not allowed to designate drugs as specialty and not allowed to steer these prescriptions to their own pharmacies.
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