PBM Steals Money From Taxpayers – Guest Post

PBM Steals Money From Taxpayers

While I’m not routinely working in community pharmacy nowadays, the impact and reach that a pharmacist in this role can have is immeasurable.  I have great respect for those that are currently working in a pharmacy.  I have crazy respect for those that actually own an independent pharmacy.  It isn’t for me, but some of the problems that I have heard reported from pharmacists regarding PBM’s are downright scary.  This impacts all of us and all of my patients. I came across this article “PBM Steals Money From Taxpayers” on Linked In written by Pharmacist Michael Corbin and couldn’t resist sharing it with my audience here.  It’s perplexing that we allow this to happen.  I appreciate Michael allowing me to share this brief situation he encountered.

PBM Steals Money From Taxpayers

I’m writing this at the request of just ONE of my patients. She needs Rivastigmine patches, her doctor authorized the use of the generic, the patient wants the generic but the PBM requires the use of the BRAND. The brand cost the pharmacy $622.90, the generic cost the pharmacy $145.00

As you can see there would be a large savings for the patient and Medicare (aka Taxpayer) but because the PBM is receiving a large Rebate (normal people call it a kickback, but that is illegal, so PBM’s call it a rebate) this patient and Taxpayers spend Hundreds of Dollars every year for this one drug, just for her. Tens of Thousands of patients need this medication, most are on Medicare. This adds up quickly to Millions of Dollars spends on this one drug alone.

To be clear this is a common practice in the PBM industry. The questions are all Why’s?

  • Why does the Government let PBM’s do this?
  • Why does HHS let PBM’s do this?
  • Why does the Attorney General in each state let PBM’s do this?
  • Why does the US Attorney General let PBM’s do this?
  • Why does every Senator and Congressman, Congresswoman let PBM’s do this?

Authored by Pharmacist Michael Corbin

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  1. Eric Christianson

    Thanks for the comment Mel, I will do a little more work and try to get a little further info from the author on this one. – Best, Eric

  2. Eric Christianson

    Michael is going to look to see if he can get more information on this one. I probably could have been a little more judicious in the choosing of the title as I took it from his LinkedIn post. I can appreciate that perspective on the title. As far as this not being a clinical post, cost and drug availability affects us all and in virtually every clinical decision/recommendation. Unfortunately, cost is always a factor. It is something I think about with every patient and it can be really time consuming, error provoking, and challenging to switch patients from one medication to another due to formulary changes. There can especially be so much confusion with our geriatric population. Best, Eric

  3. Haik

    Mel, if you need lessons on PBM’s and how they practice, I can offer you some. Every pharmacist is a clinical pharmacist and this concerns everyone. So thank you Eric. This is huge part of today’s healthcare and as pharmacists we expect and thank you for all of your articles. Please, don’t ever be intimidated by PBM’s or their pressures.

    Thank you!

  4. June

    This did occur in my practice as well. Then the PBM would switch back to generic preferred if you did not catch it your pharmacy got burned. Just reality folks so do not blame Eric. -A former independent pharmacy owner.

  5. Lawrence Riccio

    Working in independent retail pharmacy last night and I receive a prescription for rosuvastatin 10mg 1 HS #90. I process the prescription to find out only brand Crestor is covered. Ok, I reenter the Rx for Crestor and get a paid claim. When I go to reorder the 90 Crestor I find out that the pharmacy is being reimbursed $733.00 and the wholesaler is charging us $753.33 . I also see the generic rosuvastatin is $14 for 90. I ask my tech and she tells me that if I process 30 that we would make $5.00 otherwise the patient would need to use mail order. I should mention that this prescription is for a Medicare insured patient!

    How are we letting the Pharma, PBM, and Insurer (PPI) gangsters get away with this! Let’s look at this game a little closer and see who the winners are in this game. It’s obvious the biggest loser is the United States healthcare consumer and the non 1% taxpayers.

    The winners:

    Astra Zeneca – Revenue for Crestor for 2016 was $3.6 Billion most of which comes from US consumers. So the company ensures that the sales remain robust for a brand name drug whose sales should be dead by aligning itself with legal gangsters aka The PBMs. Net result more money for the executives and more profits for shareholders.

    The PBM- This is a whale of a drug for a PBM. Imagine the rebate they make from Astra-Zeneca on a drug that lists for $753 and in reality should be priced at $20. Also they are making more money based upon percentage from the insurer when a drug is priced exhorbitantly high and in addition increase their own PBM mail order pharmacy business by forcibly steering all the Crestor fills to mail order (They also make a fee on each rx filled by mail order). The mail order pharmacies are happy as they are able to buy the drug a at very sweet discount and make a good margin, inflate their net revenues, and pirate clients away from the independent and the non-mail order pharmacies which is much easier to do with very expensive drugs rather than inexpensive generics in this very rigged system. Net result more money for the executives and more profits for the PBMs and Mail-Order Pharmacies.

    Insurers- As the money that is “paid out” increases so does our premiums and the amount that the government ( U.S taxpayer) subsidizes. More money for the executives and more profits for shareholders.

    Why are we using a drug that has a FDA approved generic that costs approximately 5000% less and when there are alternative generic statins?

    The government subsidizes the insurance industry and indirectly the PBMs and Pharma but they are able to operate their rackets with little transparency and regulation. No other country in the world allows this to happen! If NATO is unfair to the US taxpayer what is this disgrace?

    By the way, I filled the Rx for 30 tabs made $5 for the pharmacy and now I’m worried that they’ll put me in jail.

  6. June Caldwell

    I recall a brand name requirement from a PBM many years ago which switched back to generic without notice. I did not discover the formulary change before the medication went out the door with the patient, so our business took the loss – not the patient or the PBM or the taxpayers. Often it was difficult to focus on what really matters – like counseling the patients on their medications – when reimbursements are so often unfair and sometimes below the pharmacy’s actual cost (not including overhead!). Unfortunately this problem is a reality folks. I am a former independent pharmacy owner x2. Regards, June

  7. Lawrence Riccio

    The US consumer deserves to know where his/her insurance premium and taxpayer money is being spent. “These PBM middlemen are getting rich and this needs to stop” – President Donald Trump

  8. TR

    Yes, this is one way the PBMs manipulate pharmacies and patients. While the patient is on Medicare it might not matter until they hit the doughnut hole, then they are responsible for ~50 % of that cost. Which doing the math one can easily see how the genetic would save the patient money.

    2. Another manipulative way the PBM works by gaining more money from patients is based on amount submitted. If what is submitted is over what the insurance will pay they will pass that amount to the patient. At independent pharmacies it’s known as negative reimbursement. If more people knew about this I’m sure it would outrage people.

    3. 3rd manipulation is how PBMs can MAC prices on medications. The PBM can pretty much reimburse whatever they want on generic drugs. We are constantly MAC appealing because the PBM doesn’t pay our pharmacy enough for the cost of the drug.

    4. A 4th was the PBM is manipulative is DIR fees. This is some random fee they charge for certain prescriptions about a month or two after they paid you for the prescription. So you think you made $20.00 on a RX until you get the remittance and see they charged an $18 DIR fee. Now you made $2.00. Not sure what the answer is but it would be nice if the PBMs could be monitored. They are never really audited and can do whatever they want. I could go on and on how PBMs are driving independent pharmacies out of business. Those are a few examples of how they are unfairly doing business. I could go on and on. I will leave it at that for now. Rant over. 🙂


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Written By Eric Christianson

November 28, 2018

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