Tag: Pharmacy benefit manager
Follow the money
A few days after my success getting insurance coverage for a 3-month supply of my daughter’s specialty medication, I learned that my husband’s employer was switching to a new specialty pharmacy. This meant that a new organization was now handling all the logistics of getting the drug to may daughter – the paper work, the shipping, collecting of co-pays, etc.
While this was very frustrating news, it was not surprising. Specialty drug spending has increased dramatically in recent years. While there is no standard definition of specialty drugs, these are the high-priced drugs (> $600/month) that are often given by injection and are used to treat serious inflammatory conditions (like rheumatoid arthritis or Crohn’s disease), infections (like HIV and hepatitis C) and many types of cancer. These drugs are often amazing – they save lives and improve symptoms in people who would have suffered greatly in the past. Sadly, companies are competing to make money from these high-priced drugs.
It is easy to blame drug companies for the high price of specialty drugs but they are not the only ones who make money on these drugs.
Our insurance mess
A few months ago, I read the horrifying story in the New York Times written by a physician, Aaron Carroll entitled “Trapped in the System: A Sick Doctor’s Story”, about how difficult it was for him to get his prescription filled. At the time I joked with my husband that the story didn’t sound that bad to me. My daughter has been taking “specialty drugs” (expensive drugs that are used to treat complicated medical problems like cancer, rheumatoid arthritis and multiple sclerosis) for several years and we have had many frustrating experiences, especially trying to figure out the medical bills. Her recent switch to a new specialty drug has caused the biggest problems yet.
Most insurance plans use other companies, called pharmacy benefit managers or PBMs, to manage prescription drugs. And PBMs use companies called “specialty pharmacies” (often owned by them) to manage specialty drugs, which are a key factor in driving up healthcare costs.