EDITORIAL:
Express Scripts Attempts to Change its Identity!
A full-page advertisement in The Wall Street Journal, and perhaps other media, captured my attention, but quickly lost credibility.
WE'RE PHARMACISTS.
WE'RE CLINICIANS.
WE'RE RESEARCHERS.
WE'RE NEGOTIATORS.
WE'RE CAREGIVERS.
THAT'S NOT A MIDDLEMAN.
THAT'S AN ADVOCATE.
The ad continues:
"We're Express Scripts by Evernorth. We're not middlemen."
"We're 18,000 advocates who take pride in being the last line of defense for millions of Americans against rising health costs. Fighting every day to make their medications more affordable and accessible."
It is of interest that Express Scripts is concerned about being characterized as a "middleman," because that is the most charitable designation with which pharmacists and many others would describe the company and its programs. To claim to be an "advocate" for anyone other than its own employees and investors is blatant deception. To claim to be making medications "more affordable" denies the reality in which almost everyone other than Express Scripts and other PBMs consider medications to be less affordable.
The first claim in the ad is "WE'RE PHARMACISTS." I do not question that Express Scripts employs some pharmacists but it is unacceptable that it attempts to achieve credibility by identifying with our trusted profession. How many pharmacists are included among its 18,000 employees/"advocates?" Are there any pharmacists in the executive and upper-level management groups and, if there are, what positions do they hold? As a pharmacist, I am offended that a company that is so destructive of our efforts to achieve professional, patient-centered goals attempts to seek credibility by identifying with our trusted profession. Our pharmacy organizations should reject this claim of a company that has non-negotiable policies and provides compensation to pharmacies that is so abysmal that it is the major factor in the closure of pharmacies for financial reasons and the formation of "pharmacy deserts."
The other identities that Express Scripts claims can also be challenged, particularly that of "Caregivers." In the context of healthcare, the word suggests a personal relationship between the recipient/patient and the provider of care. How many of the employees at Express Scripts have that responsibility? Do any of them? Or is this a deceptive strategy to claim credit for the care provided by local pharmacists? Telehealth and other remote communications, to the limited extent they might be used by Express Scripts when requested by prescription recipients, can't justify the claim of caregiving.
Express Scripts is NOT a company of Pharmacists or Caregivers! Its executives and other decision-makers are IMPOSTORS!
Although the claim of being Negotiators has some credibility, the claim of making "medications more affordable and accessible" is not credible. Pharmaceutical companies (Pharma) establish a list price for a drug that results in a PBM "request/demand" for a rebate in a continuing circular process that increases the costs of medications. Both PBMs and Pharma are at fault for this mutual enrichment system that creates an unsustainable challenge for patients, health professionals, government, and society. The damages and costs that result are beyond the scope of this editorial and will be addressed in a future commentary.
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EDITORIAL:
A Pharmacist's PBM Odyssey (Still Unresolved)
In late July my wife experienced respiratory symptoms and tested positive for COVID. She was prescribed Paxlovid and it was provided at our local independent pharmacy (Paoli Pharmacy) and there was no co-pay or other charge. Two days later, I experienced similar symptoms and tested positive for COVID. Because I have chronic kidney disease at a stage at which Paxlovid is not recommended, I was prescribed Lagevrio (molnupiravir) which is less effective than Paxlovid but is the only other approved orally-administered option. Lagevrio is seldom prescribed and Paoli Pharmacy did not have it in stock. Rather than have me delay starting treatment, the pharmacist offered to contact the next closest pharmacy (you guessed it! – CVS) to see if they had it. They did and she transferred the prescription.
Because I did not want to expose anyone else to my symptoms, a family member picked up the prescription. I have Medicare and Humana prescription plan coverage but I was charged a co-pay of $540.95 for the 5-day course of treatment. When my symptoms resolved, I sought clarification as to why the prescription co-pay was so high. I called CVS and left a voicemail message. My call was returned the following day by an individual who said that CVS does not determine the price and co-pay, and that I should speak with someone at the insurance company. I asked if he was a pharmacist and he responded "no," and I asked to speak with the pharmacist. After approximately 5 minutes "on hold" the pharmacist picked up and said that it was an insurance issue and I should contact them, or speak to the CVS manager who was not there that day. She provided the first name of the pharmacist manager and I requested her last name. She responded that she did not know it because she was just filling in that day.
I called Humana and, over the course of approximately 2 hours (much of it "on-hold"), I spoke with 6 different individuals to whom I was transferred. To their credit, everyone was courteous (as was I as I managed to suppress my frustration). I received conflicting explanations for the high co-pay including the deductible in my plan, the formulary tier of the drug (both Lagevrio and Paxlovid are in Tier 3 with higher co-pays), and that prior authorization had not been provided. The prior authorization "explanation" from 3 different individuals covered the entire spectrum of possibilities (i.e., Lagevrio required prior authorization but Paxlovid didn't, both drugs required prior authorization, and that neither drug required prior authorization). I was informed that I was not charged the full price for the drug and that Humana had covered a substantial part of the cost. I was provided 3 different figures for the total cost of the drug by different individuals that were close to each other but not the same ($900+). The first 5 individuals with whom I initially spoke or to whom I was transformed included supervisors but none was a pharmacist. I informed the fifth individual that I would like to speak with a pharmacist and I was transferred to a pharmacist. I explained my concern about the amount of the co-pay and asked why my wife was not charged a co-pay for Paxlovid using the same prescription plan when both of us have had similar utilization of the prescription plan for medications that are available generically and inexpensive. The pharmacist responded, "I don't know why you were transferred to me because I work in the mail-order pharmacy," that presumably does not dispense either Lagevrio or Paxlovid because of the need to start treatment as soon as possible. However, she offered to help identify an explanation and would get back to me.
The Humana pharmacist called me the following day to say that she had learned that Lagevrio had 2 National Drug Code (NDC) numbers. The NDC on the claim that had been submitted for my prescription ended in 09, and the co-pay was assessed. If the claim had used the NDC code that ended in 06, there would have been no co-pay.
I called CVS again to request clarification regarding the multiple NDC codes. The pharmacist with whom I spoke stated that the product with the NDC code ending in 09 was the commercially-available product and the only one they had, and noted that a different NDC code might have been used when the product was first made available under FDA's Emergency Use Authorization (EUA) and was funded by a different program. (Lagevrio continues to be available under the EUA).
I then called Merck, the manufacturer of Lagevrio. I was informed that there had been multiple NDC codes and that the one ending in 09 was for the product that was now supplied. The individual informed me that there was a coupon available on the website lagevrio.com. The website message begins: "Pay as little as $10 per prescription up to a maximum program savings of $300 per patient." I initiated my request and clicked on the link to continue, and was greeted with the message, "We are sorry this page is not available at this time." I tried again later and was successful in submitting a request, but almost immediately received the response, "Based on the information provided, you are not eligible to participate in this coupon program. For any questions, please call 877-267-2454." I called this number and the automatic response stated that it was the McKesson Consumer Support Line. When a representative was available, I explained my concerns and asked for information as to how I could file a complaint. I was placed "on-hold" and shortly thereafter there was a busy signal and the call was disconnected. Although I had provided the phone number from which I was calling, I have not received a return call.
The "take-aways"
I intend to persist in my efforts to seek clarification of my concerns and a substantial reduction in the amount of my co-pay. At this time, my "take-aways" from this experience are the following:
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Following discussions with individuals at four huge corporations (CVS, Humana, Merck, McKesson) that are involved in the distribution and claims management for prescription medications, not only have my concerns NOT been adequately addressed or clarified, but I have also been provided with conflicting responses.
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The number of individuals involved in the adjudication of prescription claims is very labor-intensive and adds huge administrative costs in the extremely cumbersome process through which prescription medications are dispensed, co-pays are assessed, and claims are processed. My unsuccessful discussions with six different individuals at Humana is a primary example.
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Prescription benefit managers (in this case, Humana) impose greater control on the selection, distribution, use, and cost of medications than any other organization or participant, including the company that makes the drug, and the prescriber and pharmacist (i.e., the health professionals providing the care and information for patients).
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Prescription benefit plans provided by PBMs are extremely but unnecessarily complex, very difficult to understand, almost impossible to navigate, and very unlikely to achieve satisfactory resolution of questions and concerns. The current system must be reformed and greatly simplified.
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I need to obtain additional clarification, but one individual informed me that the federal government bought huge supplies of Paxlovid that continue to make it possible to obtain prescription with no co-pay "while supplies last." Does this represent discrimination by not including Lagevrio, a less effective but still valuable product, and by necessitating that patients who are not only afflicted with COVID but who also are experiencing other medical issues that preclude the use of Paxlovid, are charged a co-pay because they need Lagevrio?
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COVID-19 has caused incalculable deaths and continuing physical, mental, and financial harm. Information that has accumulated strongly suggests that the virus is not of natural origin but was constructed at the Wuhan Institute of Virology with the financial assistance and knowledge of U.S. agencies and officials, and was disseminated via a "lab leak." This likelihood must be confirmed and the Chinese Communist Party and the individuals in the U.S. who are culpable in the occurrence of the pandemic must be held accountable.
To be continued. . .
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