Doctor's mandating all or none on prescription approval.

[MountainPharmD]

I think that's a fair approach to things. Though as a prescriber, I'd certainly want to know if patients aren't picked up all of the meds (especially in the previously mentioned antibiotics/narcotics example).

Page #2 and Z is a biatch!!!!!


We would tell the patient we needed to call the doctor to get approval. 99% of the time this was deterant enough.

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[pezdispenser]

I thought your [MountainPharmD/PBM] job was what's wrong with pharmacy. What do we do when the PBM rejects the Januvia? Refuse to give them any of the medication? I mean all or nothing, right?

We need PBMs and formularies, otherwise doctors would just prescribe whatever they want because some hot drug rep told them it's better in some miniscule way, or a patient swayed by all the direct to consumer advertising always asks for the best, money no object. PBMs need to be there to look at the cost effectiveness, otherwise costs would skyrocket out of control.

Unfortunately this makes the PBMs look like the bad guys, denying treatments and making Prior Auth headaches. As an aside, in case anyone is against socialized medicine because of the so called "death panels" and "rationing of care", well we already have them in place with managed care, right here, right now...

But I think one of the advantages of socialized healthcare is that it is one uniform system so it is much simpler for providers and patients to abide by. Right now, with all these competing PBMs, each with their own formularies, networks and rules, heck plan sponsors can even choose different formularies within the same PBM, it's just too complicated for pharmacists, doctors and patients to follow. Still, I think we can keep the privatized system with some improvements.

Like I run a script for enalapril and it just says "Drug not covered" (true story!). Need to waste time calling the insurance and find out the patient needs to use mail order. Why don't they just tell me that in the reject message?

Or one plan prefers one brand name drug over another in the same class, perhaps because they get a better deal from the manufacturer, while another plan prefers a different drug. Well the poor doctor is just guessing what's covered. Usually, they don't find out until after the pharmacy runs it, and of course we need to call them to change it, wasting more time. The technology is there for the PBMs to provide the formularies specific to the patient's plan right there at the point of prescribing in the EMR or CPOE, so that the doctor can just prescribe what's covered the first time.

 

[npage148]

I have no issues with formularies but the lack of transparency and the anti-patient cost saving measures (mandatory mail-order, etc) are what make PBMs so bad.

I'd much prefer a gov't coordinating death panel vs a private one. At least with the gov't maximizing progits (at the expensive of not providing care) isn't their sole function.

The other day I was trying to bill a flu shot via Caremark. It was declined and I called and they said "the patient should go to a free clinic to get it" The patient went w/o. Caremark just avoided providing care to make their bottom line better. In the end, they will just cost their contracted company (in this case) more money because if the patient gets the flu they are going to the ER. They just deny care and push costs around

 

[All4MyDaughter]

Medco waited until a Friday night when I was out of insulin to tell me that I could no longer fill it at a local pharmacy and would have to use mail order. They said my only choice was to pay cash for it or GO TO THE EMERGENCY ROOM if I couldn't afford it. Yes, I'm certain that United Healthcare would be thrilled to pay for that ED visit (or complications to me and my extremely high risk pregnancy if I just went without insulin) because Medco passed the buck. *******s. But United just dumped Medco and now we have CVS/Caremark as our PBM. So we'll see.

 

[MountainPharmD]

Medco waited until a Friday night when I was out of insulin to tell me that I could no longer fill it at a local pharmacy and would have to use mail order. They said my only choice was to pay cash for it or GO TO THE EMERGENCY ROOM if I couldn't afford it. Yes, I'm certain that United Healthcare would be thrilled to pay for that ED visit (or complications to me and my extremely high risk pregnancy if I just went without insulin) because Medco passed the buck. *******s. But United just dumped Medco and now we have CVS/Caremark as our PBM. So we'll see.

Bridge therapy department. You would have had your insulin and an order sent out via mail order.

 

[All4MyDaughter]

Bridge therapy department. You would have had your insulin and an order sent out via mail order.

I went through two levels of supervisor and was told there were no more options.

 

[MountainPharmD]

I went through two levels of supervisor and was told there were no more options.

This is with Caremark. They have a whole department that does nothing but bridge therapy for people who are waiting on mail order.

 

[All4MyDaughter]

This is with Caremark. They have a whole department that does nothing but bridge therapy for people who are waiting on mail order.

Sounds good. I believe that (per our plan) I can also get 90DS of my regular meds at the local CVS, which is what I'll probably do. One of my former students is now the pharmacist at the neighborhood CVS. I'd like to get them filled where I work, but the options seem to be CVS or mail order. But at least no more insulin after next Tuesday (I hope!).

 

[MountainPharmD]

I have no issues with formularies but the lack of transparency and the anti-patient cost saving measures (mandatory mail-order, etc) are what make PBMs so bad.

What is this about transparency? Is the pricing where you work transparent? Hell is there any pricing on any consumer good that is transparent? I think it is hilarious everyone wants PBMs to lay out every little financial detail. Really? Why stop at PBM's? Every consumer good's pricing should be transparent.....cars, a gallon of gas, TV's. While your at it lets have some transparency at the pharmacy. Lets exposed the profit margin there so people know exactly what there paying for.

Explain how mail order is anti-patient? I hate to break this to you but the company signing up for the insurance is the one who decides if they are going to have thier employees use mandatory mail order not the PBM. Your lack of understanding of the process is laughable.

If you are pissed off you have to get your scripts through mail order do not be pissed at Medco, Express scripts or Caremark. Be pissed at your employer for selecting that option when they signed up for the benefit. It has nothing to do with the PBM. The PBM manages the pharmacy benefit how the employer or plan sponser wants it managed. From mail order to drugs on prior auth to drugs not covered all can be selected by the employer or plan sponsor when they sign up. There are hundreds of different ways a plan can be set up from a standard basic set up to a totally customized plan..

 

[pezdispenser]

I have no issues with formularies but the lack of transparency and the anti-patient cost saving measures (mandatory mail-order, etc) are what make PBMs so bad.

I don't care about pricing transparency. That's between the plan sponsors and the PBMs. My pharmacy does not disclose reimbursement rates or acquisition costs either. That's just the way it has to be when you have healthcare run by private enterprises competing in a free market. If healthcare were socialized, with a single government payer, sure, then you can have all the pricing transparency you want.

Mandatory mail-order, like MountainPharmD has said many times, is a choice made by the plan sponsor, not the PBM.

But I would like to at least see more transparency in informing everyone--patients, pharmacists, doctors--about how their plans work, like what is and isn't covered, networks, etc. Plan sponsors and/or PBMs have done a very poor job of this.

 

[All4MyDaughter]

Yes, plan sponsors elect for mail order, but let's not pretend that the PBMs don't heavily promote and incentivize it. I'm not convinced that PBMs save plan sponsors a ton of money. They are siphoning it off as their own profits.

 

[MountainPharmD]

Yes, plan sponsors elect for mail order, but let's not pretend that the PBMs don't heavily promote and incentivize it. I'm not convinced that PBMs save plan sponsors a ton of money. They are siphoning it off as their own profits.

Sure the PBM's are in it to make a profit. Just like everyone else in health care. You are in it to make a profit. So is retail pharmacy, insurance companies, doctor's, lawyer's, pharmacy and medical schools.....and on and on and on......

 

[MountainPharmD]

But I would like to at least see more transparency in informing everyone--patients, pharmacists, doctors--about how their plans work, like what is and isn't covered, networks, etc. Plan sponsors and/or PBMs have done a very poor job of this.

Seriously? They do to the nth power. A patient is provided evey single piece of information concerning ther plan either online or paper copies.

People are lazy and stupid and choose to throw it in the trash, ignore it or assume someone will hold their hand, wipe their ass and take care of it for them like everything else.

 

[owlegrad]

Seriously? They do to the nth power. A patient is provided evey single piece of information concerning ther plan either online or paper copies.

People are lazy and stupid and choose to throw it in the trash, ignore it or assume someone will hold their hand, wipe their ass and take care of it for them like everything else.

Yes, I am sure A4MD just throw away all the warnings she was sent about needing to use mail order to get her insulin.

 

[MountainPharmD]

Yes, I am sure A4MD just throw away all the warnings she was sent about needing to use mail order to get her insulin.

I bet she didn't read it.

 

[owlegrad]

I bet she didn't read it.

Yeah that sounds like her.

 

[All4MyDaughter]

I bet she didn't read it.

Yeah that sounds like her.

Yeah, busted. I'm always VERY cavalier about life-saving interventions that affect my health and the life of my unborn child. "Oh you sent me a notice about my insulin? NOT IMPORTANT!"