Freedom of choice

[hoosierpharmacist]

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I searched for some threads that cover a patients freedom of choice to chose a pharmacy and couldn't find anything. If its out there please go ahead and direct me to the right place. Anyways,

There are regulations that prevent pharmacies from entering into contracts/agreements/whatever you wanna call it with prescribers to protect a patients freedom of choice to chose a pharmacy. However, as a student, i've been running into some situations that seem to conflict with this. How are these not illegal?

Ex #1 : tried to get a PA for a patient. We were told to send their info to a covermymeds website and drs office sent it back to us and told us to tell the patient to go to a different pharmacy where GoodRx gave them x $$

Ex #2 : this happened to me. I have filled at a pharmacy for the past 2-3 months. My caremark insurance told me that they wouldn't cover it at that pharmacy anymore now that a CVS was just built down the road. Someone told me if I call them its easy to get out of it, I'm just waiting to do it until it comes closer to a refill. Regardless, not everyone knows this and i'm sure for some it seems like they are pressured into using CVS or not being covered.

 

[ChalupaBatman86]

They can force you to use mail order for maintenance meds. And CVS counts their retail stores as part of Caremark's mail order network. So they are not forcing you to CVS retail, they are forcing you to mail. Retail mail. MailTail if you will.


Sent from my iPhone using SDN mobile

 

[PharFromNormal]

So most of this had to do with network arrangements and these conversations here can get quite political on what is defined as "force."

A big part of the nuance comes from who and how the medication is paid for (and with who's negotiated leverage). When you remove the financing or reimbursement of prescriptions, anyone can pretty much get a prescription generally filled anywhere (with some extremely limited exceptions).

A pharmacy may not be in a network or have a network status that is not as favorable on the patients copay amount compared to another pharmacy for a plethora of different reasons ranging from the pharmacy was not offered to be included by the PBM to the pharmacy (or the organization they pay to make these decisions) made a business decision that they don't want to accept the terms/reimbursement from the PBM that comes with an attractive patient pay amount.

In legal speak the words "force" and "ability" have very literal terms. A PBM can't "force" anyone to fill anything anywhere. They do however strongly influence a patients behavior when the patient is dependent upon the benefits that the PBM manages.

Cash is king. Typically a PBM throws their weight around to get the total Reimbursement a pharmacy receives for a prescription down. They often times use the allure of potential massive volume shifts to the pharmacy willing to take less on a per unit basis.

At the end of the day - prescriptions can be paid in full in cash by the patient.

(Cue incoming NCPA anti-PBM speak. Including "pharfromnormal is a PBM shill")

 

[PumpkinSmasher]

I searched for some threads that cover a patients freedom of choice to chose a pharmacy and couldn't find anything. If its out there please go ahead and direct me to the right place. Anyways,

There are regulations that prevent pharmacies from entering into contracts/agreements/whatever you wanna call it with prescribers to protect a patients freedom of choice to chose a pharmacy. However, as a student, i've been running into some situations that seem to conflict with this. How are these not illegal?

Ex #1 : tried to get a PA for a patient. We were told to send their info to a covermymeds website and drs office sent it back to us and told us to tell the patient to go to a different pharmacy where GoodRx gave them x $$

Ex #2 : this happened to me. I have filled at a pharmacy for the past 2-3 months. My caremark insurance told me that they wouldn't cover it at that pharmacy anymore now that a CVS was just built down the road. Someone told me if I call them its easy to get out of it, I'm just waiting to do it until it comes closer to a refill. Regardless, not everyone knows this and i'm sure for some it seems like they are pressured into using CVS or not being covered.

I work in ambulatory care and use good rx from time to time. I inform my patients of the price options and let them make the choice. in my area, kroger usually has best good rx price for sidenafil 20mg, acne meds and various other meds not covered by insurance.

There is no legality concern, pt tells me they want the cheapest price so I tell them where in these instances.

 

[npage148]

Not with xyrem

 

[PharFromNormal]

Not with xyrem

Correct, limited distribution drugs is one of the limited exceptions as it relates to the pharmacies inability to physically get access to the medications in the supply chain. Even in some (not all) of these situations pharmacies can invest to get the requirements they need to get this access if they want this access. I don't think OPs examples refer to this type of situation.

 

[lord999]

So most of this had to do with network arrangements and these conversations here can get quite political on what is defined as "force."

A big part of the nuance comes from who and how the medication is paid for (and with who's negotiated leverage). When you remove the financing or reimbursement of prescriptions, anyone can pretty much get a prescription generally filled anywhere (with some extremely limited exceptions).

A pharmacy may not be in a network or have a network status that is not as favorable on the patients copay amount compared to another pharmacy for a plethora of different reasons ranging from the pharmacy was not offered to be included by the PBM to the pharmacy (or the organization they pay to make these decisions) made a business decision that they don't want to accept the terms/reimbursement from the PBM that comes with an attractive patient pay amount.

In legal speak the words "force" and "ability" have very literal terms. A PBM can't "force" anyone to fill anything anywhere. They do however strongly influence a patients behavior when the patient is dependent upon the benefits that the PBM manages.

Cash is king. Typically a PBM throws their weight around to get the total Reimbursement a pharmacy receives for a prescription down. They often times use the allure of potential massive volume shifts to the pharmacy willing to take less on a per unit basis.

At the end of the day - prescriptions can be paid in full in cash by the patient.

(Cue incoming NCPA anti-PBM speak. Including "pharfromnormal is a PBM shill")

Agree with the above in total, and I'll add a couple of exceptions that are truly "force" as in there is a law with respect to this:
1. If you got the prescription from a federal source (VA, IHS, FHCC), the feds can force (in all the meanings of the word) a patient to receive the fill for that prescription from an approved federal source. There's usually not a reason besides cost why a patient would take the script out of the feds anyway, but if the script was written with dispense VA only, it stays within the system, no exceptions. In practice, we only do so for narcotics or things of that nature where there is cause for tracking, we're happy to give Walmart, CVS, and groceries business when it's financially cheaper for the veteran to do so like BP and antibiotics.

2. If you are uniformed, this also includes Tricare for certain meds (opioids and psychiatric drugs), where there are actual rules for active duty service members that say that if you do not get those meds from a DoD approved source, they are contraband. If you are caught with something as benign as Wellbutrin as a uniformed member and it did not come from a DoD approved source, that is an immediate confinement situation. It's the one case where a PBM can "force" a member to comply as the ruling is not from the PBM, it's the "company" which in this case is ASD, HA. So, if I know a person is uniformed military, no, they may pay cash for this drug if it's Percocet, they must fill it through Tricare Management Authority approved pharmacy using the plan or at an MTF.

3. If the drug happens to be an officially controlled product, you have to work with whoever the control agent is:
a. Blood and Albumin - American Red Cross (by law, Title 42)
b. Methadone (by law, Title 21)
c. Biologicals (by regulation deriving from Title 42 to FDA, used in HGH in the past and a couple of cases)
d. INDs (by law, Title 42, amended to allow mercy exceptions but still is controlled)

So, there are actual cases where a patient is actually forced to use a specific provider, this is not the usual patient, and it's almost always something that deals with federal control. But for almost all situations, force means "force" from economic restraint, not impossible restraint. You pay for access.