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 Easily Lose FAT And Love Longer!!

When you exercise or reduce calories your fat is changed in to water and carbon dioxide. The water mixes into your circulation until it’s lost as urine or sweat and you exhale the carbon dioxide.

You lose more weight through exhaling the carbon dioxide than you do in your urine or sweat. Sounds crazy doesn’t it!

Just about everything we eat is removed via our lungs. This applies to all the carbohydrate, proteins and fats that we eat are changed into water and carbon dioxide, even alcohol is removed via the lungs and urine.

Only dietary fibre goes in to your colon. Everything else you ingest goes into your organs and bloodstream and then evaporated in your breathing.

Is It Only About Calories In v. Calories Out? Continue reading “How To Easily Lose FAT And Love Longer!!”

How To Avoid Knee Pain, Ouch!!

How To Avoid Knee Pain, Ouch!!

To Keep Knee from Hurting

To keep your knees healthy, follow these simple tips. Dos for Healthy Knees: Always see a doctor if you experience knee pain that is not relieved by several days of rest, ice, massage, and elevation. Back off from activities such as walking hills or knee-bending exercises that cause you pain.

Why Do Our Knee Hurt? Continue reading “How To Avoid Knee Pain, Ouch!!”

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”

A Strategy To Survive Your Future

This is a strategy that I have recently adopted into my own life. It’s a subtle reminder that everything – the good and bad, pleasure and pain, approval and disapproval, achievements and mistakes, fame and shame – all come and go. Everything has a beginning and an ending and that’s the way it’s supposed to be.

Every experience you have ever had is over. Every thought you’ve ever had, started and finished. Every emotion and mood you’ve experienced has been replaced by another. You’ve been happy, sad, jealous, depressed, angry, in love, shamed, proud, and every other conceivable human feeling. Where did they all go? The answer is, no one really knows. All we know is that, eventually, everything disappears into nothingness. Welcoming this truth into your life is the beginning of a liberating adventure. Continue reading “A Strategy To Survive Your Future”

What You Need To Know About NY EPIC & Medicare Part D

EPIC AND MEDICARE PART D
            The open enrollment period for Medicare Part D closed earlier this month, but there is another way to save money on your prescription drug coverage you can explore.  EPIC (Elderly Pharmaceutical Insurance Coverage), is a New York State program that provides supplementary drug coverage and premium assistance for seniors with Medicare Part D.  As an added benefit, EPIC enrollees are able to change their Part D plan outside of the open enrollment period one time, any time during the year.
            EPIC is open to any New York State resident who is age 65 or older and has an income up to $75,000 if single or $100,000 if married.  To receive EPIC benefits, you must be enrolled in a Part D plan.  EPIC may even help pay the Medicare Part D drug plan premiums for members with income up to $23,000 if single or $29,000 if married. Higher income members are required to pay their own Part D premiums, but EPIC provides premium assistance by lowering their EPIC deductible.
            Seniors who are not eligible to join a Medicare Part D drug plan cannot join EPIC. Examples of ineligible seniors include those with a union/retiree drug subsidy program that is not a Part D plan, and seniors without Medicare Part A or Medicare Part B. Seniors with Medicare Advantage health insurance can only join EPIC if they have Part D drug coverage with their HMO.
            It is very important to show both your EPIC ID card and the Medicare Part D plan card at your pharmacy to receive the maximum prescription benefits.
            Two other important things to know:
            A senior who receives full Medicaid benefits is not eligible for EPIC. 
            If your Part D drug plan has an annual deductible, you must pay the deductible before EPIC coverage will begin. 
            You can find the application (in eight languages), as well as more information about the program, online at https://www.health.ny.gov/health_care/epic/application_contact.htm or by calling EPIC toll free at 1-800-332-3742
            No documentation is required. EPIC verifies information with the Social Security Administration and the New York State Department of Taxation and Finance.

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Mouthwash May Be Cause Diabetes & Obesity

 

I know it sounds crazy!!!

It Kills Good Bacteria!

In a 2016 study, researchers found evidence that the popular mouthwash Listerine can control gonorrhea bacteria in people’s mouth and throat.

While the antibacterial fluid is used to kill harmful oral bacteria, researchers of the new study said that it could also be indiscriminately killing the beneficial strains of microbes that provide protection against obesity and diabetes, as well as those that help the body produce nitric oxide.

Nitric oxide helps regulate the insulin levels of the body. It plays an important role in regulating metabolism, balancing energy, and keeping the body’s sugar levels in check. 

Frequency Of Use

  • Mouth washes act on all bacteria in the mouth, the good and the bad. By removing the good bacteria it permits the harmful bacteria to grow and increase.

Latest research is recommending that you should limit your use of mouthwash to just once a day to avoid eliminating the helpful bacteria in the mouth.

Please subscribe and share this information, it may save a life.

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”

Treat Obesity & Diabetes With Cinnamon- Lose 30 Pounds In 30 Days

Treat Obesity & Diabetes With Cinnamon

We have been telling you this for a long time!

Benefits Of Cinnamon

Recent research is reporting that common Cinnamon which is popular food ingredient can lower cholesterol levels, relieve Alzheimer’s disease symptoms and is associated with decreasing the risk of diabetes and obesity.

Cinnamon is an obesity killer. A tablespoon per day will help you lose 30 pounds within a month!

Fat Cells

Continue reading “Treat Obesity & Diabetes With Cinnamon- Lose 30 Pounds In 30 Days”

For people on Medicare, there are some changes to be aware of for 2018

 

For people on Medicare, there are some changes to be aware of for 2018

SOCIAL SECURITY

“Medicare is going to replace everyone’s Medicare card starting in April 2018 through April 2019. The cards will be replaced on a scheduled basis. Everyone will get a new card that will have the Social Security number removed and replaced with a unique ID number. It will look different. Nobody needs to initiate anything.”

SCAMS

“There are a lot of scams. There are people calling Medicare beneficiaries, saying they need to pay $35 for these new cards. But Medicare will never call to verify a Medicare number,” or ask for money.

For people on Medicare, there are some changes to be aware of for 2018.

The open enrollment period for Part D prescription drug plans and Part C Medicare Advantage plans is Oct. 15 through Dec. 7.

Prescription drug plans, known as Part D, are advisable for people on Medicare if you are not enrolled in an HMO with drug coverage.

In the past, Medicare allowed companies to merge their enrollees with existing plans,”  we have not heard if that is still true.

It’s important to read the annual notice of change from your company. “If people choose not to renew, they have extra time to find other coverage, but it’s important to pay attention to the dates.”

You shouldn’t risk a coverage gap. If this particular plan ends Dec. 31, you have until Feb. 28 to renew. But that leaves two months uncovered — you don’t want to do that.

People who have prescription drug coverage from a retiree plan do not need to enroll in a Part D plan. You don’t need to do anything. If you have credible coverage from a former employer or the Veterans Administration, you don’t need to enroll. Continue reading “For people on Medicare, there are some changes to be aware of for 2018”