Zurik: Drug consumers seek relief as PBM's make money hand over fist
NEW ORLEANS (WVUE) - A few taps on Carol Shoemaker's phone saves her hundreds of dollars in the pharmacy.
"It's crazy, it's distressing," Shoemaker says, "the amount of money you pay for insurance. I pay between $600 and $700 a month for a premium because I'm a single person, I don't have a company, you know, getting any discounts with big group insurance policies. So, it's very distressing - you're already spending a ton of money on insurance, but you still have to pay for, you know, all of the extra."
Shoemaker almost paid a lot more for one drug; it cost $613 with her insurance. But instead of using that insurance, Shoemaker logged on to one of those cost-saving prescription apps - in this case, GoodRx - and paid just $272 for the medication.
"For me, that's just too much money to be throwing out the window," Shoemaker tells us.
She shows us a printout - her family's medications, with the savings she found online. Shoemaker says those annual savings add up. "It could be a thousand bucks," she says.
And last year she could have saved even more: She used her insurance for a $277 cream, but only later found out she could have paid just $11.72 via an app.
"My husband's going to kill me for that," she jokes, noting the $260 in missed savings would have bought "a nice pair of shoes."
Pharmacy benefit managers, or PBM's, control these costs for your prescription drugs.
"The PBM's in everyone's pocket," warns Doug Hoey, who heads National Community Pharmacists Association. "I mean that literally and figuratively because, in every wallet or purse, that prescription drug card that people carry around, somewhere in the fine print, it'll usually say the name of the PBM, the pharmacy benefits manager."
The three biggest PBM's are CVS/Caremark, Express Scripts and Optum, which is owned by United Healthcare.
"They're huge," Hoey says. "They're probably companies you've never heard of. But they're bigger than the drug manufacturers."
Here at WVUE/FOX 8, Caremark manages our prescription medication. We compared some of the prices our colleagues were being charged.
We found one antibiotic, Ciprofloxacin that costs $15 through our insurance at the Walmart pharmacy. Using GoodRx, the same medication can be bought for just $4. And we found similar savings on an arthritis drug, Meloxicam.
"It doesn't make sense," Hoey says. "It's counterintuitive. I mean, you stroke a check each month to pay your premium and you expect that to give you some value. And the reality is that, in increasing numbers of cases, if you just did it the good old-fashioned way of paying cash, you might pay less for your prescription."
FOX 8 investigators reached out to Caremark for comment on this report. They sent us this statement:
Without knowing who the CVS Caremark members are or the details of their prescription transactions, it is not possible for us to look into their situations in order to either explain their experience under their specific coverage plan, or clarify any incorrect or incomplete information you may have been provided.
CVS Caremark is committed to ensuring that our PBM clients and members have access to affordable medications to improve health outcomes. To that end, our PBM plan members receive the lower price when covered prescriptions are filled by a pharmacy that participates in their plan's applicable pharmacy network. For example, we set a negotiated rate for generic medications with pharmacies, but if a pharmacy in our network has a cash price for a medication that is less expensive than our negotiated rate, the pharmacy is required to submit that lower price when it processes the prescription claim through Caremark.
We found plenty instances where drug costs on insurance were cheaper than those without. But the lesson remains: A smart consumer needs to shop around, ask for the cash prices on their medications, look online and on apps, and ask the insurance prices, too.
A big case in point: We received a list of medications for employees of the Orleans Parish School Board. In 2016, employees paid $28 for a high blood pressure drug, Lisinopril. But through GoodRx, it would have cost them just $8.
"It does not make sense and it happens a lot," says Gerald Michel. He runs two pharmacies and he says customers frequently come in and save money paying cash for medication.
Michel wonders if there's more savings out there.
Take the Orleans Parish School Board - all of those prescriptions add up. Just like your employer may do, taxpayers subsidize part of school employees' prescription expenses. In 2016, they cost taxpayers $1.5 million.
But savings exist by bypassing those high-priced pharmacy benefit managers or PBM's. Michel also sits on the Terrebonne Parish Council. Two years ago, he urged the council to dump its PBM and search for a new one.
They found one right here in Louisiana, in Natchitoches. Terrebonne dumped its PBM, Optum; Southern Scripts signed a deal with the parish and saved taxpayers $1.2 million on pharmacy costs last year.
"Ultimately, it's the person getting the insurance that's going to be saving the money," Michel says.
"When you think about $1.2 million for... 3,000 people in that county, or 3,000 employees, and if you extrapolate that over 200 million workers in the United States... I'm not that good a whiz to figure out what that number is, but it has a lot of zeroes," Hoey says. "It starts at least with a 'b', as in billions. And that's the type of potential savings that's out there, that's right under our counties', employees', school districts'... That's right under their noses right now, by not using transparent PBM."
The head of the pharmacists group says he knows another story of a company saving even more on prescription costs. "They saved 30 percent," Hoey tells us, "30 percent off their prescription drug spend, which is a lot of money."
In the meantime, PBM's are raking in lots of cash; Americans are spending about $400 billion on prescription drugs every year.
"These are very profitable companies," Hoey notes. "They're all traded on Wall Street, they have shareholders they have obligations to. And so, yes, they're going to make sure they're profitable and are rewarding those shareholders."
Unless consumers start shopping around, experts warn, those growing profits will come at the expense of pharmacies, consumers and taxpayers.
If you do pay cash for a medication.... It could impact whether you reach your deductible. so be sure to investigate that.
You can read much more in our "Medical Waste" investigation at this link.
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