Please think of your PBM’s profits when you fill your next prescription (I’m begging you)
A few weeks ago, my daycare-faring toddler came down with a cold. Surprise, surprise. About a week after her first symptoms, she started showing signs of something more sinister, so I made a same-day appointment at our pediatrician’s office. We took her in for a check-up, and it was confirmed: she had a run-of-the-mill sinus infection. The clinician wanted to treat her with a standard dose of amoxicillin, and they shot the ePrescription over to our local Walgreens. All was well. It was just another Monday in our house, or so I thought.
When I hit the pharmacy drive-thru about 4 hours later, the prescription wasn’t ready. As it turned out, the Walgreens system needed to verify some of my daughter’s basic demographic information before it would attempt to process the claim with our health plan’s PBM, Express Scripts. The experience was a bit of a pain, but “No matter,” I thought, “I’ll verify the information, they’ll submit the claim, it will be instantly approved, and I’ll just spend the next 20 minutes swiping at my phone in the parking lot until the prescription is ready.”
Little did I know, our PBM was about to make something clear: I was mistaken.
Express Scripts’s reply to Walgreens’s claim processing attempt read something like:
“Well, we’ve decided not to cover this prescription today. We know it’s a generic antibiotic for a toddler’s sinus infection that is inexpensive, is commonly prescribed, and is the recommended dose for her age and weight, but we’re going to mandate you get a prior authorization anyway. Have you considered asking your kid’s pediatrician to prescribe a brand name drug that would drive a higher rebate for us? Does your toddler really have a sinus infection, or is she just crying and acting out for attention? Good thing we’re here to stop this prescription from getting filled - your kid might have recovered too quickly!”
Well, perhaps it actually said ‘PA Required - dosage limit’ - we’ll never know for sure. But, here’s what I did know: requiring a prior authorization for a simple antibiotic that met standard clinical guidelines for care was a great example of the American healthcare system, where many of our policies are designed to err on the side of maximizing corporate profits (such as driving patients to drugs that drive higher rebates for their insurers) over patient’s health outcomes.
As a parent with a coughing and snotting toddler at home, and as someone who knows a thing or two about prior authorizations and drug pricing at the point of sale, I realized I had a three options:
I could cross my fingers, hope the prior authorization would be approved within the average 72 hours, let my kid feel miserable while keeping her home from daycare in the meantime, and ultimately pay the insured price ($7), or
I could pay the Walgreens cash price ($39.99) and fill the prescription immediately, or
I could hold up the drive-thru line a little longer, find a GoodRx coupon to lower the cash price ($13.50), and still get the prescription today.
Now, I know what you’re thinking: “Nick! For the love of all that is holy, do not pick option 2! How on earth would your benevolent PBM profit if you paid cash to the pharmacy directly?!”
(IYDK:If you pay cash for you prescription at the pharmacy, the PBM doesn’t get a cut)
I know, I know. On top of fearing for Express Scripts’s bottom line, I could hardly stand the thought of losing the prescription’s $7 contribution towards my family’s $13,000 out of pocket maximum (yes, really, $13,000).
American Family Values Vs. American Business Values
As I started to think through my next steps, I wondered aloud “would a true American let their toddler’s immediate health needs get in the way of their health plan and PBM’s overzealous and shoddy utilization management tools?”
I knew MedMutual of Ohio and Express Scripts had worked hard to put this barrier to quality and affordable healthcare in place, and I mulled over my patriotic duty to (needlessly) inject profits into their executives and shareholders pockets directly from my wallet. Was I ready to leave even one middleman out of the piece of pie that was the money I was prepared to spend on this prescription?
Time slowed down as I mulled over the bevy of suits who might be left high and dry if I made the wrong decision.
Torn between my toddler’s health and the fate of Cigna/ExpressScripts’ Q3 earnings call, I settled for option 3 and prayed GoodRx was able to share some revenue with them.
The Big Reveal
After I resolved my agonizing decision-making process, Walgreens decided it was time to reveal that it only had half the required amoxicillin on hand to fill the prescription. So, with a partially filled prescription, I put my tail between my legs and made my way home.
I made a second trip back to Walgreens two days later to fill the rest. After a few days, my daughter recovered and we were able to move forward with life as usual.
What Might Have Been (And What Is For Many)
More seriously, my family spent more time and money than we would have had our payer and PBM not decided to put a prior authorization requirement on a near no-cost prescription that met the clinical criteria for the patient and their diagnosis. We’re lucky, as it turns out. My daughter's condition was relatively benign, we’re able to afford these generic medications, and since I’ve spent my career focused on healthcare and many years focused specifically on prior authorizations, I understood my options.
For many, the process to get one’s prescriptions covered by their health plan and PBM, especially prescriptions for medication critical to one’s life, is overly-complex and unnecessary, and you can expect you, your children, friends, and loved ones to be sicker and poorer in the interest of a system built to drive profits for the few. Your PBM and health plan won’t mind - in fact, they’ll make sure those barriers are in place! I’ll get into this another day, but there are groups of people at PBMs and health plans actively working to implement these schemes today. I’ve had conversations with many of them.
One way or another, the inconvenience, the delay, the workarounds - they’ll all work for them and against you. It’s all going as planned.