In a piece for the New York Times, Rebecca Robbins and Reed Abelson advise readers on how to avoid overpaying for prescription drugs. Most importantly, you should not assume that your insurer is saving you money on your drugs. Too often you will pay more for your drugs with insurance than you would if you paid for your drugs in full, without insurance.
How is it possible you would pay more for your drugs with employer coverage or Medicare Part D coverage than without it? Three words: Pharmacy benefit managers or “PBMs.” These entities—prescription drug middlemen who work for health insurers and are often owned by them—are responsible for negotiating with pharmaceutical companies for lower-priced drugs. But, they can and do pocket a lot of the savings. They then determine which drugs your insurer will cover and your copay for each drug, your “formulary.”
Three big corporations own the three biggest PBMs. UnitedHealth owns Optum Rx, CVS owns Caremark and Cigna owns ExpressScripts. These insurance corporations put their shareholders’ interests ahead of their customers’. What’s worse is that our government allows them to upcharge their customers.
Robbins and Abelson suggest that you might want to know which PBM controls your formulary, but I’m not sure why. Caremark, ExpressScripts and Optum control 80 percent of the prescriptions filled in the US. And, there’s no evidence that any of them offer better prescription drug coverage than any other.
How do PBMs game the system? In addition to being able to pocket and not pass along to you the discounts they secure from drug manufacturers, they can force you to take a brand-name drug when a lower-cost generic is available. They take money from the brand-name manufacturer to steer you to its drug and away from the generic; they might not include the generic on their formulary.
Sometimes, PBMs include generic drugs on their formularies, but they charge copays for these drugs that are higher than the full cost of the drugs without insurance.
What can you do? Always check to see whether you can get your prescription drugs at a lower price from Costco or GoodRx or Mark Cuban’s Cost Plus Drugs or from abroad. You often can. A colleague of mine was told the Medicare Part D copay for his drug was over $300. When he asked the cost with GoodRx, he was told it was $30!
Here’s more from Just Care:
Leave a Reply