We need to get rid of PBMs and just be reimbursed based on per script basis. How the faq does pbms get away this thievery?
Surprisingly not often because the neighborhood I work at is mostly medicaid and medicare patients so the pay isn't too bad. There is very few people with actual insurance and in those cases we can barely get away with breaking even depending on the medication. The doctors here have their own formulary they select off of and if something pays terribly for us, we give a call to the front desk and ask if we can change to ___. For the most part, if the change is based off a that list they gave the front desk, they just say yes to the change without needing to call the doctor. Examples being omeprazole > esomeprazole or mucinex 600 > 400mg. Two doctors here even lets us freely change between drugs of same class as long as doses match (Probably has too much trust in us). One of them just wants us to notify them of changes so they send refill scripts matching the change.
Im thinking it may be beneficial for us, indie pharmacists, to get our resources together and start an on going list of meds (with specific ndcs) with good reimbursements. Anyone?
Was the idea of changing drugs initiated by the doctors or the pharmacy? if you pitched the idea, how did you approach the doctors about it?
They've long been doing it since before I started working here. From what I can tell, the doctors are also patients of the pharmacy and have been so for years. The doctors get swamped with phone calls for changes often and after doing it so often (Like insurance formulary switches from Invokana > Tradjenta > Farxiga + Tradjenta > Steglatro that happened over the years), they just allow us to directly change it instead of asking for permission each time and having the patient wait.
A published list that is readily available is a great way for the PBMs to realize they're reimbursing too high and immediately correct it.
Good. That would level the playing field for those whose committing fraud. Ive seen pharmacies with list of meds on a rx pad that had high reimbursement drugs and would have doctor just check off on everything. Run what ever drug that pays. some drugs had reimbursements in hundreds or even in thousands.
Damn do such drugs really exist anymore. Aside from very few generics that pay in the hundreds and are only prescribed to a few patients who have been in hospitals or are patients that persistently badger their doctors to give it to them, most stuff pay crap. Even most brand names right now have an almost non-existent of $1-2 profit compared to our order price but then turns negative because there is some additional fee we have to pay for ordering brand names.
We do a similar thing with a convenient care across from where I work. There are only so many times you call saying "sorry they won't cover Pro-Air can we switch to Ventolin" or something similar before they say it's fine and to just make the switch without having to call. Whenever a new provider is there we call once and just say "hey for future reference is it ok if we make that switch without calling....100% of the time they have said yes"
