How Obamacare Pushes Big Pharma To Overcharge You

As if our health care “system” wasn’t already complicated enough, here’s example No. 9,572.

I spent the better part of one year trying to ask a prescription drug provider one simple question about my prescription. Even as someone who works in health policy and with advocates on my behalf, I kept getting the run-around.

Unfortunately, as I found out firsthand, big conglomerates — in this case, CVS Health — make profits by keeping the system complicated, bureaucratic, and opaque. But (eventually) I found out there’s a simple solution: returning to good, old-fashioned cash transactions.

Mail Order Madness

The saga started last summer, when my physician prescribed a maintenance medication to prevent a recurrence of kidney stones. My doctor sent a prescription to CVS Caremark, requesting a 90-day mail-order supply of the drug. CVS is the pharmaceutical benefits manager (PBM) that administers my prescription.

When it arrived, I received the following note:

We filled your prescription with a smaller quantity than what your doctor prescribed. Your prescription plan has limits on the amount of your medication it will cover. We filled your prescription according to these limits. [Emphasis original.]

For the better part of 12 months, I communicated with CVS staff, trying to figure out the reasons for this decision. I also asked a representative from the District of Columbia’s Office of Health Care Ombudsman to investigate on my behalf. Every time my physician prescribed a 90-day supply of this medication, CVS Caremark sent me a 30-day supply of the drug, along with the same note described above.

A few weeks ago, I finally spoke with a CVS representative who could tell me the reason. While my prescription plan covered the drug, it did not cover it as a maintenance medication. This explained why CVS Caremark kept lowering the medicine supplied from 90- to 30-day supplies.

The representative informed me I could use an exceptions process, through which my physician could send a form to CareFirst (my insurer) providing clinical justification to use the drug for maintenance purposes. If approved by CareFirst, then CVS Caremark would honor the 90-day prescription, and provide me with a three-month supply of the drug going forward.

This annoyed me, because I had mentioned the exceptions process (which I know about from working in health policy) while speaking to CVS personnel last summer. That individual never provided me the information I had asked for, which could have saved me months of hassle.

I contacted CVS’ corporate office to ask two simple questions: why did the notices I received refer to “your prescription plan” — a wording that seems deliberately vague as to whether my insurer (CareFirst) or the PBM (CVS Caremark) made the coverage decision; and why didn’t those notices also include specific, written instructions on how request an appeal or exception for longer-term coverage of the drug?

CVS’s communications team sent back this response:

CareFirst is the plan sponsor, and CVS Caremark helps support the administration of the plan’s pharmacy benefit. This CareFirst plan relies on an expert third-party vendor, Medispan, to determine which medications are considered maintenance drugs versus acute. Because Medispan lists potassium citrate as a non-maintenance drug, it is subject to the CareFirst plan’s non-maintenance day supply limit of 30 pills. Members have access to an exceptions process, which is administered directly by CareFirst.

This response didn’t answer my questions about notice wordings. In fact, it suggests that a heretofore undisclosed third party (Medispan) made the decision that limited my prescription. Given CVS’s non-answer, a cynic would suggest the obvious yet unstated reason the notice omitted information about filing an appeal or exceptions request: If people knew about an exceptions process, they might use it.

Pay Cash Elsewhere

Ultimately, I realized arguing with CVS Caremark over 90-day coverage of this drug wasted not just my time, but also my money. Talk of the TrumpRx platform prompted me to look into discounted options to obtain the drug without using my insurance. For instance, CVS Caremark charged me several times more ($45.81) than what Cost Plus Drugs ($10.93 plus shipping) or Pharmacy Checker (as low as $17.27) would charge me for the same prescription.

By paying cash rather than using the CVS Caremark benefits available through my insurance policy, I ended up paying less for a 90-day supply of the prescription by using a discount code at a local grocery store pharmacy than CVS Caremark would have charged me for another 30-day prescription. Paying cash means that the cost of the prescription won’t get applied to my annual insurance deductible, but as I’m on a junk Obamacare plan, I won’t meet that deductible anyway unless I have a major medical emergency.

When asked about their high pricing, CVS’ communications team claimed that “the same medication can have different member costs depending on the plan and pharmacy selected.” But as this publication and others documented, health care conglomerates like CVS often overcharge customers for prescription drugs, to shift profits from their insurance business (where profits are capped by Obamacare’s medical loss ratio) to their pharmacy business (where profits are not capped).

This story illustrates how PBMs like CVS Caremark can profit by overcharging patients for drugs, and making the prescription drug system more complicated. Patients should look into all their options. Paying cash could end up saving you a bundle of money, not to mention time.