Working around a PBM for your prescriptions is hard, but there are some options

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Pharmacists say there’s not much they can do, but discount drug programs offer a little wiggle room

Pharmacy benefit managers (PBMs) continue to play a major role in how consumers get their prescription medications -- often to the point of frustration for the patient. For those who are looking to get out of the maze, ConsumerAffairs investigated the situation to look for less stressful and more straightforward ways to deal with the drug-to-consumer supply chain. 

Following up on our story about the irritation consumers feel in dealing with PBMs, ConsumerAffairs searched for ways people can make their whole Rx process easier to deal with.

Pharmacists say their hands are tied

In a perfect world, there may be a solution to every problem, but the pharmacists ConsumerAffairs spoke to said their hands are tied.

“There are no workarounds. As a pharmacist, what you see on the screen is the answer you get,” one pharmacist, who spoke on the condition of anonymity, told ConsumerAffairs. “The PBM reports the problem based on the insurer’s criteria and enforces the blocks. They have very little ability to fix these issues and often barely offer to provide any solutions. Sadly, the workarounds are in place at the state and federal level. There is a reason the Supreme Court just ruled against PBMs for their reimbursement practices. They are devious and as close to being criminal as the law allows, at least for now.”

When ConsumerAffairs asked another pharmacist if there’s any way they could intervene in a situation where the PBM is rebuffing the consumer, the answer was also no.

“We are often given other points of contact while trying to advocate on the patient's behalf, and usually the numbers we call are patient-specific lines that create more barriers for a fix. If you do not have a high level of health literacy it is very difficult to navigate the system,” they said.

The second pharmacist also said the Medicare part D process has become a nightmare because of the push to force more prescription business online. They said dealing with that push consumes 30% of their day because they have to jump through hoops that the PBMs have created. Seniors are especially vulnerable under this system because they may not have the knowledge necessary to handle the change.

“It is incredibly frustrating that we have to manage a triple role of being the health care provider, the insurance navigator and the inaccurate target of frustration. The difficulties grow each year, and until laws are written that no longer allow profiteering of illness and fear of financial ruin, there is no end in sight,” they said.

Discount drug programs offer some hope

While workarounds at the pharmacy level might be non-existent, there are a growing number of consumers who are turning to companies like GoodRx and America’s Pharmacy --  a fairly new addition to the prescription chain that provides comparison shopping and coupons for discounts on medications. 

But do these drug discount programs provide the key ingredients of less hassle and equivalent savings? Dr. Joshua P. Cohen -- an independent health care analyst and former research associate professor at the Tufts University Center for the Study of Drug Development -- said they do.

While GoodRx and PBMs might make for strange bedfellows, Cohen said that applying GoodRx discounts can make medication prices much cheaper than the price the pharmacy charges. That’s because the company has the power to get heavily discounted drugs, PBM network discounts, and rebates. 

However, it’s important to note that discount programs and PBMs are still connected. While they may be able to provide some discounts, those deals are still being passed on by larger companies that could keep the prices artificially high.

Monique M. Whitney, executive director of Pharmacists United for Truth and Transparency, told ConsumerAffairs that not all of the layers of interaction automatically go away when dealing with a discount offer from a company like GoodRx.

“There are any number of intermediaries between the drug maker, the pharmacy and the patient, and it is those other intermediaries taking a cut of the sale that keeps prices in an ever-upward cycle,” she said.

Taking action

If you feel like you’re being taken advantage of by prices set by a PBM, Whitney says there are things you can do.

“Depending on the state the patient lives in, they can (and should) take their complaints to their state's department of insurance or attorney general,” she said.

“Too often patients think their complaint isn't ‘big’ enough to go through state government channels, but departments of insurance (DOI) and attorneys general (AG) are there for consumer protection. Also, when patients complain, the complaint becomes part of the public record. The more complaints a PBM gets, the more attention the DOI or AG will pay.”

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