PBS NewsHour: Why a patient paid a $285 copay for a $40 drug

Two years ago Gretchen Liu, 78, had a transient ischemic attack — which experts sometimes call a “mini stroke” — while on a trip to China. After she recovered and returned home to San Francisco, her doctor prescribed a generic medication called telmisartan to help manage her blood pressure.

Liu and her husband Z. Ming Ma, a retired physicist, are insured through an Anthem Medicare plan. Ma ordered the telmisartan through Express Scripts, the company that manages pharmacy benefits for Anthem and also provides a mail-order service.

The copay for a 90-day supply was $285, which seemed high to Ma.

“I couldn’t understand it — it’s a generic,” said Ma. “But it was a serious situation, so I just got it.”

A month later, Ma and his wife were about to leave on another trip, and Ma needed to stock up on her medication. Because 90 days hadn’t yet passed, Anthem wouldn’t cover it. So during a trip to his local Costco, Ma asked the pharmacist how much it would cost if he got the prescription there and paid out of pocket.

The pharmacist told him it would cost about $40.

“I was very shocked,” said Ma. “I had no idea if I asked to pay cash, they’d give me a different price.”

Ma’s experience of finding a copay higher than the cost of the drug wasn’t that unusual. Insurance copays are higher than the cost of the drug about 25 percent of the time, according to a study published in March by the University of Southern California’s Schaeffer Center for Health Policy and Economics.

USC researchers analyzed 9.5 million prescriptions filled during the first half of 2013. They compared the copay amount to what the pharmacy was reimbursed for the medication and found in the cases where the copay was higher, the overpayments averaged $7.69, totaling $135 million that year.

USC economist Karen Van Nuys, a lead author of the study, had her own story of overpayment. She discovered she could buy a one-year supply of her generic heart medication for $35 out of pocket instead of $120 using her health insurance.

Van Nuys said her experience, and media reports she had read about the practice, spurred her and her colleagues to conduct the study. She had also heard industry lobbyists refer to the practice as “outlier.”

“I wouldn’t call one in four an ‘outlier practice,’” Van Nuys said.

“You have insurance because your belief is, you’re paying premiums, so when you need care, a large fraction of that cost is going to be borne by your insurance company,” said Geoffrey Joyce, a USC economist who co-authored the study with Van Nuys. “The whole notion that you are paying more for the drug with insurance is just mind boggling, to think that they’re doing this and getting away with it.”

Graphic by Lisa Overton

Joyce told PBS NewsHour Weekend the inflated copays could be explained by the role in the pharmaceutical supply chain played by pharmacy benefit managers, or PBMs. He explained that insurers outsource the management of prescription drug benefits to pharmacy benefit managers, which determine what drugs will be covered by a health insurance plan, and what the copay will be. “PBMs run the show,” said Joyce.

In the case of Express Scripts, the company manages pharmacy benefits for insurers and also provides a prescription mail-delivery service.

Express Scripts spokesperson Brian Henry confirmed to PBS NewsHour Weekend the $285 copay that Ma paid in 2016 for his wife’s telmisartan was correct, but didn’t provide an explanation as to why it was so much higher than the $40 Costco price. Henry said that big retailers like Costco sometimes offer deep discounts on drugs through low-cost generics programs.

USC’s Geoffrey Joyce said it is possible that Costco negotiated a better deal on telmisartan from the drug’s maker than Express Scripts did, and thus could sell it for cheaper. But, he said, the price difference, $285 versus $40, was too large for this to be the likely explanation.

Joyce said it is possible another set of behind-the-scenes negotiations between the pharmacy benefit managers and drug makers played a role. He explained that drug manufacturers will make payments to pharmacy benefit managers called “rebates.”

Rebates help determine where a drug will be placed on a health plan’s formulary. Formularies often have “tiers” that determine what the copay will be, with a “tier one” drug often being the cheapest, and the higher tiers more expensive.

Pharmacy benefit managers usually take a cut of the rebate and then pass them on to the insurer. Insurers say they use use the money to lower costs for patients.

Joy said a big rebate to a pharmacy benefit manager can mean placement on a low tier with a low copayment, which helps drives more patients to take that drug.

In the case of Ma’s telmisartan, Express Scripts confirmed to PBS NewsHour Weekend that the generic drug was designated a “nonpreferred brand,” which put it on the plan’s highest tier with the highest copay.

Joyce said sometimes pharmacy benefit managers try to push customers to take another medication for which it had negotiated a bigger rebate. “It’s financially in their benefit that you take the other drug,” said Joyce. “But that’s of little consolation to the person who just goes to the pharmacy with a prescription that their physician gave them.”

But Joyce said the pharmacy benefit managers also profit when collecting copays that are higher than the cost of the drug.

In recent years, the industry has taken a lot of heat from the media and elected officials over a controversial practice called “clawbacks.” This happens when a pharmacist collects a copay at the cash register that’s higher than the cost of the drug, and the pharmacy benefit manager takes most of the difference.

The three largest pharmacy benefit managers – Express Scripts, CVS Caremark, and OptumRx – all told PBS NewsHour Weekend they do not engage in clawbacks.

But Howard Jacobson, a pharmacist at Rockville Centre Pharmacy in Long Island, NY, showed PBS NewsHour Weekend several recent examples of clawbacks. In one instance, Howardson acquired a dose of the generic diabetes Metformin for $1.61. He said if a patient paid out-of-pocket, he likely would sell if for $4. But in a recent transaction, the pharmacy benefit manager told Jacobson to collect a $10.84 copay from the patient, and it took back $8.91.

In the case of Z. Ming Ma and his wife Gretchen Liu, there was no pharmacist involved, because they purchased the medication directly from Express Scripts.

Express Scripts’ Brian Henry reiterated to PBS NewsHour Weekend that the company does not engage in clawbacks and opposes the practice. And he also blamed the health insurer, Anthem, for Ma’s high copay. “Anthem has its own Pharmacy and Therapeutics committee that evaluates placement of drugs on the formulary based on their own clinical and cost review – thus setting their own formulary and pricing,” Henry said in an email.

But Lori McLaughlin, a spokesperson for Anthem, pointed the finger back at Express Scripts. “Anthem currently contracts with Express Scripts for pharmacy benefit manager services and under that agreement Express Scripts provides the drug pricing,” she said in a statement. “Anthem is committed to ensuring consumers have expanded access to high-quality, affordable health care which includes access to prescription drugs at a reasonable price.”

McLaughlin also pointed to a lawsuit filed in March 2016 by Anthem against Express Scripts, for, she said, “breach of its obligation to provide competitive pharmacy pricing.”

As for Express Scripts’ contention that it doesn’t engage in clawbacks, USC’s Karen Van Nuys said it’s a matter of semantics. “Whenever the copay is higher than the cash price, and the difference isn’t reimbursed to the patient, someone else must be pocketing the difference,” Van Nuys said. “Maybe it isn’t technically called a clawback, but the principle is the same.”

So what’s a patient to do? Websites like GoodRx and WellRx can help consumers find the best prices at local pharmacies. They provide coupons and savings cards for certain drugs as well as out-of-pocket price information, which could be less than a copay.

It’s not always better to pay out-of-pocket, even if it’s cheaper. Patients need to look at the terms of their insurance plans and do the math.If a patient has a high deductible, it might make more sense in the long-run to pay the higher price and use up the deductible so insurance kicks in sooner.

Z. Ming Ma said he does find the Express Scripts home delivery service convenient. But he wasn’t happy about the price of his wife’s medication, and is glad he found another way to buy it.

“You have no choice, you can’t bargain,” he said. “I knew I wasn’t going to win.”

This story has been updated to reflect that Gretchen Liu is 78 years old.

How To Improve Your Brain & Body- InsuredMeds.com

How To Improve Your Brain & Body

Protect Your Brain: You can effect conditions like Alzheimer’s /Dementia, depression and your health by getting in the habit of only a half hour a day of physical activity at least three times a week. Alzheimer’s /Dementia, depression and your health by getting in the habit of only a half hour a day of physical activity at least three times a week.

How It Works: • Physical activity will boost your energy and mood. Continue reading “How To Improve Your Brain & Body- InsuredMeds.com”

Sugar Industry Hid Its Link To Obesity & Diabetes

Sugar Industry Hid Its Link To Diseases

Investigators report that industry misled us all!!

They misled us that it was fats

In the 1960s, a debate began over the effect of sugar and fats on cardiovascular disease. Researchers say that the sugar industry, wanting to influence the discussion, funded research to look into sugar consumption.

And when it found data suggesting that sugar was harmful, the powerful industry pointed a finger at fats.

Newly uncovered historical documents indicate the industry never disclosed the findings of its work and effectively misled the public to protect its economic interests.

Food Industry

The researchers’ claim that the sugar industry misled the public mirror accusations the tobacco industry faced. A trial was held in 2004 to determine whether tobacco industry officials had intentionally deceived Americans for years into thinking that smoking did not cause cancer, despite acknowledging the dangers of smoking among themselves.

Eight months later, the tobacco industry was asked to pay $10 billion over five years to help millions of Americans quit smoking. The penalty was less than 8 percent of what the government had asked for when proceedings began.

Sugar Paid Off Studies

Continue reading “Sugar Industry Hid Its Link To Obesity & Diabetes”

Have You Heard of Harry The Hypnotist?

It was entertainment night at the Senior Citizens Centre.
After the community sing-along, led by Alice at the piano, it was time for the star of the show – Harry the Hypnotist!

Harry explained that he was going to put the whole audience into a trance “Yes, each and every one of you and all at the same time,” said Harry.
The excited chatter dropped to silence as Harry carefully withdrew, from his waistcoat pocket, a beautiful antique gold pocket watch and chain.

“I want you to keep your eyes on this watch” said Harry, holding the watch high for all to see.

“It’s a very special and valuable watch that has been in my family for six generations,” said Harry.

He began to swing the watch gently back and forth while quietly chanting, “Watch the watch — watch the watch —- watch the watch”

The audience became mesmerized as the watch swayed back and forth.
The lights were twinkling as they were reflected from its gleaming surfaces.

One hundred and fifty pairs of eyes followed the movements of the gently swaying watch.

They were all hypnotized.

And then, suddenly, the chain holding the watch broke!
The beautiful watch fell to the stage and burst into fragments on impact.
“SHIT!”  shouted Harry.
It took the staff three days to completely clean up the Senior Citizens Centre and Harry was never invited back again.
When nothing goes right…  Go left.

Humor is good for you, please subscribe and share this senior joke.

Adult Dance Classes Increase Weight Loss & Mental Health

Adult Dance Classes Increase Weight Loss & Mental Health

The Connection:

The reason why people dance tango is to get the feeling of connection. No other dance allows such a close and deep connection. This is why people persist with that goal for a very long time. If it were not for that, people would give up the dance requires a lot of sustained effort to develop that connection. It’s human nature – we all want to connect with other humans.

The beauty of tango is in the oneness of the union rather than the performance of the individual. In tango nothing is ornate, but everything is exquisite and elegant. To tango is to indulge yourself, not to impress others.

On a crowded dance floor who cares about your footwork anyway. The only thing that matters is the feelings you experience. Continue reading “Adult Dance Classes Increase Weight Loss & Mental Health”

Why Do Seniors Get Shingles? One Out Six Seniors Will Get it !!

Why Do Seniors Get Shingles?

One Out Six Seniors Will Get it !!

Shingles Overview

Almost 1 out of every 3 people in the United States will develop shingles, also known as zoster or herpes zoster, in their lifetime. There are an estimated 1 million cases of shingles each year in this country. Anyone who has recovered from chickenpox may develop shingles; even children can get shingles. However the risk of shingles increases as you get older. About half of all cases occur in men and women 60 years old or older.

Some people have a greater risk of getting shingles. This includes people who Continue reading “Why Do Seniors Get Shingles? One Out Six Seniors Will Get it !!”

HFCS Hidden In Plain Sight – What you didn’t know!

 

HFCS Hidden In Plain Sight

What you didn’t know!

Exposed!! The Ugly Truth About High Fructose Corn Syrup (HFCS)

The corn crop in the United States is heavily subsidized, high-fructose corn syrup is also cheap.

As a result, it’s now used in so many foods, from crackers to soft drinks, that it has become one of the biggest sources of calories in the American diet. Continue reading “HFCS Hidden In Plain Sight – What you didn’t know!”

Chocolate Can Keep The Doctor Away

  • Chocolate Can Keep The Doctor Away Chocolate Heart
    • Recent research is showing that people who consume some chocolate during the week improve their heart health.
    • It turns out that chocolate has compounds called “polyphenols” that increases blood flow and improves vascular health.

    It is also being reported that the compounds in Cocoa may help reduce inflammation.

    Dark Or Milk Chocolate? Continue reading “Chocolate Can Keep The Doctor Away”

Insomnia & Sleep Apnea Effect On Seniors

Insomnia & Sleep Apnea

Poor Quality Sleep

  • Researchers at University Of California recently reported that the quality of sleep especially among the elderly can cause brain deterioration and substantial memory loss.
  • In the area of the brain where long term memory is stored called the prefrontal cortex receives transferred brain wave memories from the hippocampus which are produced during sleep.

Poor quality of sleep in seniors triggers memories to be trapped in the area called hippocampus and not go to the prefrontal cortex. Causing difficulty remembering names and forgetfulness.

Sleep Disruption & Memory Loss Continue reading “Insomnia & Sleep Apnea Effect On Seniors”

FREE! Newburgh Swing Dance 1st Thursday Of The Month

FREE! Newburgh Swing Dance 1st Thursday Of The Month-Swing dancing with lesson & live music. Every 1st Thursday of the month at the Newburgh Brewery at 88 Golden Street, Newburgh, NY.

Swing dancing can enrich your life! Make new friends and expand your world! No partner or experience needed!!