Monday, August 22, 2022

Generic Crestor Pricing Insanity

For a number of years, I've used a statin drug (like 35 million Americans in the United States do). Also for more than a few years, these drugs were rather costly and protected by exclusive patent protection, although at the time, they were mostly covered by my insurance to prevent major heart attacks which could cost them even more (hundreds of thousands of dollars in claims).

I've used several different low-dose statins over the years, mostly for their preventative benefits. I initially began with Pfizer's Lipitor (atorvastatin calcium), but I experienced some pretty severe muscle aches which made it difficult for me to even get myself out of bed in the morning because my leg muscles were so cramped, which was not OK for a drug I did not even HAVE to be taking. As it turned out, muscle aches are a very common adverse effect of many statins. So my doctor switched me to rival AstraZeneca's Crestor (rosuvastatin calcium) which worked better, so I stayed on it. I use a single, 10 mg tablet daily. Statin drugs are not complex biologics; they are simple, small-molecule drugs which means they are incredibly easy to manufacture.

When I was still covered by United Healthcare, that company even sent me a free pill-splitter and suggested that I could slash my out-of-pocket costs in half by asking my doctor to prescribe the statin at twice the potency of the drug I had previously used, effectively taking a half-tablet instead. Evidently, the company paid the same exact price whether it was for a 10 mg tablet as it did for a 20 mg tablet which defied logic. Two single 90-day orders lasted me all year (because I cut the tablets in half). Since then, I've learned that nothing in pharmaceutical pricing makes any logical sense and it's best not to try and analyze it beyond how it impacts me personally at the time.

Broken Generics Market, Too

The U.S. market for prescription drugs is fundamentally broken. Nowhere is this more clear than in the market for generic drugs. A 2018 study from Consumer Reports showed a survey of pharmacies' cash prices for five common generic drug prescriptions. The results were rather startling. Prescription prices ranged from $66 to $1,351 — which Drug Channels reported (see HERE) was "a nearly 2,000% difference. The big three retail drugstore chains — CVS, Walgreens, and Rite Aid — consistently had higher average prices compared with those of other pharmacies."
 

Drug Channels added in a section of the post which it called 'The Warped Logic of Pharmacy Pricing', writing:

"Some prescriptions have no third-party payments, because patients pay the full cost out of their pocket. Patients buy these prescriptions at a pharmacy's usual and customary (U&C) retail list price — the price that a pharmacy charges to a cash-paying consumer.

Why do pharmacies persist in publishing U&C prices that provide ludicrous profits margins from the neediest patients?

The unfortunate answer concerns the pharmacy industry's own little gross-to-net problem.

A third-party payer will not reimburse a pharmacy above the pharmacy's U&C list price. Consequently, pharmacies typically establish U&C prices that exceed the maximum expected reimbursement from any payer. In doing so, the pharmacy eliminates the risk that it could be reimbursed an amount less than what a third-party payer would have been willing to pay.

Hence, CVS set its average cash price at $928 for the five prescriptions surveyed by Consumer Reports. That's at least 33 times higher than the published acquisition cost. As the largest buyer of generic drugs, CVS has an acquisition cost that was likely even lower."

Generic Financial Gamesmanship


Eventually after maneuvering around brand-name drug pricing games, then came multiple generics. I was under the (mistaken) impression that would lead to cost-savings. Historically, the introduction of multiple generics means prices would fall, and prices did come down, but only somewhat. However, the generic drug market for U.S. drugs is also very fundamentally broken. More than half of the drugs themselves are made offshore in India, China, Malaysia and elsewhere which costs the companies next to nothing, and yet the prices on many of them remain stubbornly high due to endemic financial gamesmanship from entities in the drug distribution system.

Statin drug prices have been adversely impacted by PBM profiteering. In fact, I would not be surprised if they end up playing a prominent role in the litigation from the attorneys general of virtually every U.S. state and territory alleging illegal price-fixing collusion among generic drug manufacturers. Anyway, when I was still covered by Cigna, I never even noticed the price it because under my plan, the company had adopted the 2019 IRS rule (see my coverage at https://blog.sstrumello.com/2019/09/in-2020-people-with-diabetes-may-wish.html for detail) classifying statin drugs (as well as insulin) as a "preventative treatment" eligible for pre-deductible coverage, therefore I paid nothing for the drug.

Then, my employer healthcare plan sponsor switched carriers from Cigna to Aetna (then recently acquired by CVS Health). Initially, I presumed both companies would treat "preventative" treatments all the same. Unfortunately, that was untrue. Insurance companies can pick and choose which drugs they wish to treat as "preventative" treatments; no doubt their actuaries evaluate whether the tax benefits are worth more than overcharging the masses. 

When I ordered my first 90-day supply using Caremark mail order pharmacy, I was charged a ridiculous price of $33.85 for that 90-day supply, meaning MY cost was about $0.38/tablet. Again, not horrifically overpriced, but it just SEEMED kind of high to me for a new generic with lots of companies making it. A search around the internet confirmed that was no bargain. So I decided there was no way I was being robbed like that again. While Caremark charged patients nearly $34 for 90 tablets, its Aetna sister business unit was only crediting me about $7.50 for spending all that money; thereby padding someone else's bottom line at my expense.

My First Go-Around Bypassing Insurance Was Successful

As noted, although the price I was charged for generic rosuvastatin calcium 10 mg tablets wasn't obviously overpriced, but because I had discovered Caremark was overcharging my spouse for another generic drug called eplerenone 50 mg tablets made in India (overcharging us by a stunning 82% for that generic), I decided to check out prices for ALL of the generics used in my household just to be sure.

My Expectation of 56% Savings Was Established This Year

At the time, I discovered I could buy rosuvastatin calcium 10 mg tablets for considerably less (56%) at a price of just $15.00 for 90 tablets by using CVS Caremark's biggest rival, United Healthcare's Optum with an OptumPerks coupon purchased via Optum Store. Since my doctor had already given me an undated paper script for it, I investigated and discovered that at the time, Optum would accept a mailed-in prescription (others do not; they only accept e-scripts). It is my opinion that a price around $15 for 90 tablets of rosuvastatin calcium 10 mg is likely a "fair" retail price close to the actual cost-plus a small margin for the drug; anything vastly over that amount is simply price-gouging by some entity/entities.

Optum's Unexplained, Unjustified 40% Price Increase

That plan worked for most of spring 2022 except for very my last refill in June, when Optum unexpectedly raised the price on the drug by a stunning 40% to $21.00 for a drug they previously charged me just $15 for. I was annoyed, but still felt justified because I still paid less than the $33.85 CVS Caremark intended to charge me for the same prescription. Fortunately, I only incurred that inflated cost just once, then I had satisfied my own deductible so it was back to Caremark, only this time they were paying the entire cost (at least until the deductible resets next January).

Deductible Resets Routinely Expose "Covered" Patients to Bogus Rx Drug Prices

However, it occurred to me that I would be back to this stupid overpriced generic market dysfunction effective on January 1, 2023. And, I was bothered by the lack of transparency enabling this to happen and the fact that prices were subject to change at any time because the PBM saw an opportunity to make even more money. So I did what I did last year, and got on my computer and began searching for better prices.  I discovered that generic Crestor and all other statin drugs are oddly overpriced right now. We cannot blame raw material cost increases for this; its because someone is behind the scenes, manipulating the prices. And, I'm quite certain we can blame the PBM's for most of that.

Rx Coupons: Some Are PBM-Powered, Others Are Not. Alternatives to Coupons Exist, too.

Anyway, since most (not all) coupons are powered by different PBM's (some like GoodRx have non-excusive contracts with multiple PBM's although they only have access to a single formulary from each PBM which limits its ability to always deliver the lowest prices), so I turned first to non-PBM powered coupons, including SingleCare https://www.singlecare.com/ which are retailer provided discount prices which is often impressive on generics and medical devices like test strips and CGM sensors. The second one I turned to was ScriptHero https://www.scripthero.com/ (which is mainly powered by CoverMyMeds, plus the PBM MedImpact as well as SingleCare). Suffice to say, I was rather underwhelmed by the discounts I found. The lowest price I found there initially was $24.65 for 90 tablets which was not materially better than the price I paid with my insurance company's PBM Caremark.

ScriptHero (owned/operated by drug wholesaler McKesson and powered internally by CoverMyMeds, as well as the PBM MedImpact and SingleCare; I'm not sure how it chooses which input to use, but I suspect it uses CoverMyMeds whenever possible, and then turns to the others when CoverMyMeds isn't able to discount a particular drug). ScriptHero's price WAS better than SingleCare's price was: the lowest price with ScriptHero was $15.44 for a 90-day supply, but it was from a small, independent pharmacy I've never patronized before and I was worried knowing PBM's sometimes pay those pharmacies LESS THAN their actual acquisition cost for the drug (which sounds like it should be illegal; maybe FTC will eventually conclude just that?) that the price might potentially be lower than their acquisition cost for the drug, so I didn't necessarily jump at it (although I could have), but at least I had a viable alternative at a price much lower than I was paying.

So I explored further.

Costco: Powered by the PBM Navitus Which It Co-Owns

I know, for example, that Costco actually co-owns the PBM known as Navitus, so I looked at Costco's prices. Sometimes, on generics, their prices are pretty decent. But Costco's prices were marginally more expensive than the alternative options I already explored: Costco's price for a 90-day supply of rosuvastatin calcium 10 mg was $20.99 (or $21.99 if I used its mail order pharmacy which I prefer for small-molecule pills), so I wasn't enamored with that, although it was certainly better than what Caremark intended to charge me.

New Coupon Site from New PBM: CapitalRx Advantage Savings

There was an alternative I never tried before: According to Forbes (see https://www.forbes.com/sites/joshuacohen/2022/02/02/capital-rx-aims-to-disrupt-the-pbm-market/ for the article) CapitalRx is currently the nation's fastest-growing PBM. CapitalRx is an anomaly in that it uses National Average Drug Acquisition Cost (NADAC) prices and sells at a cost-plus a fixed, flat fee per prescription claim processed rather than proprietary rebates off the average wholesale price or wholesale acquisition cost. CapitalRx also does not engage in secretive rebating or spread pricing.






CapitalRx says it now serves hundreds of thousands of covered lives. The company grew by 400% in 2020, and doubled in size in 2021. Matt Gibbs, President of Commercial Markets, projects that CapitalRx will have close to one million covered lives by the end of 2022. And, CapitalRx owns/operates a coupon-generating website/app of its own as rivals Optum, Express Scripts and MedImpact do. Its coupon-generating website/app is called Capital Rx Advantage Savings https://capitalrxadvantage.com/ which I never used before. But it was worth a look. As it turned out, the prices at all of the pharmacies in its retail network was $16.04.


I could have bought generic Crestor using another coupon-generating website/app for a price of $15.44, though I was still concerned it might be screwing a small, independent pharmacy by paying them less than the drug costs them because it still uses a traditional PBM model. 

Alternatively, Costco was an option at a price of $20.99 for 90 tablets (I can literally walk to my nearest Costco, so IMHO, they ARE a neighborhood pharmacy. But lines at the store and parking there are both nightmares), and price wasn't even the lowest. Then, it occurred to me: what about COMBINING Costco with a CapitalRx coupon?

Suddenly, I discovered a price that was not available on its website (CapitalRx only provides 5 choices in the immediate vicinity of your zip code, whereas it expands it on your phone): Using a CapitalRx Advantage Savings coupon AT Costco yielded a price of just $6.54 for a 90-day supply of 10 mg tablets of rosuvastatin calcium tablets! I really couldn't believe it. I will verify this at Costco pharmacy, of course, and then ask them if I can fill future refills via its mail-order pharmacy to avoid the parking nightmare that is my local Costco store.

CostPlus Cash-Pay Only Rx Drug Options

There is yet another worthy alternative possibility worth looking into:

A growing roster of cash-only (no insurance accepted) pharmacies now exist, including most prominently Mark Cuban's CostPlus Drug Company https://costplusdrugs.com/. I discovered Mark Cuban's CostPlus Drug Company sells 10 mg tablets of generic Crestor for $5.70 for a 90-day supply + $3.00 Pharmacy Labor Fee + $5.00 shipping charge bringing its total cost for the drug to an impressive $13.70 which was quite good. But I double-checked several less heard-of rivals, including Blueberry Pharmacy https://blueberrypharmacy.com/ based outside of Pittsburgh which gives the customer a choice from several generic manufacturers (the cheapest of which was priced at $17.20 for a 90-day supply manufactured by Ascend Laboratories) or a Texas-based rival ScriptCo Pharmacy https://scriptco.com/ which had prices generally comparable to Blueberry.

And My Likely Winner Was Mark Cuban's CostPlus Drug Company, Possibly With Costco/CaptialRx PBM Coupon as the Alternative

While the Costco/CapitalRx combination seemed to be the lowest-price, things could potentially change by January. However, a big reason I might still opt to go with CostPlus is because it has no "membership fee" which has to be factored into the equation for total out-of-pocket. Remember, this is to buy a single generic drug made in India. I don't use many others and don't want to pay for membership (Blueberry charges $5/month, ScriptCo has a $50 membership fee which is billed quarterly, up to $200 annually which supposedly covers the cost of shipping. But you need to use a LOT of generic drugs to justify that). Also, big pharmacy chains like Walgreens also have a prescription savings club which charges an annual fee of $20. However, my general rule is to never pay any sort of membership or enrollment fee.


 

 

 


The point is the number of options for getting generic drugs like generic Crestor by bypassing insurance has never been greater. Unfortunately, patients are left to figure it all out by themselves which is a major hassle. As I said, I think I'll go with Mark Cuban's CostPlus for this go-around given its prices seemed to be lowest and most reliable at those prices. But I won't again be victimized by PBM and insurance company gamesmanship on what are supposed to be inexpensive generic drugs.

Again, I wish this nonsense wasn't necessary, but at least I'm more competent in the Rx shopping game than most others. Maybe someone can use my experience as a guide.

Author P.S., September 23, 2022: So, I recently filled a prescription for a 90-day supply of generic Crestor (rosuvastatin calcium) 10mg tablets. This was an example whereby I opted to simply bypass the pharmacy benefit of my own insurance because my own insurance company's PBM Caremark was ripping me off. That happens about 25% of the time according to academic research. I actually bypassed insurance since the beginning of the year. Initially, I got the medicine from rival Optum Store (which is owned and operated by United Healthcare Group). For the first three refills, I paid just $15 compared to $23.40 Caremark intended to charge me. Then, with my last refill, Optum unexpectedly raised the price to $21, which was still less than the price Caremark would have charged me. Still, I was perturbed by a 40% price increase, but I had no refills remaining, so I paid it knowing it was still a tiny bit cheaper than Caremark would have charged me. I could have insisted that Caremark pay for this drug since satisfying my deductible, but the savings wasn't worth the hassle, hence I simply opted to continue bypassing my own insurance for this medicine.

I ended up buying generic Crestor at Mark Cuban CostPlus Drug Company for a price of $10.70 (and the price includes $5 for shipping), which was actually a price reduction from what I paid earlier. Mark Cuban CostPlus Drug Company also revealed an NDC number, which was 72205000399. A quick search on the internet at NDCList.com https://ndclist.com/ revealed that particular drug was actually sourced from Novadoz Pharmaceuticals, LLC, which is a Piscataway, New Jersey-based generic drug company, although I believe the company relies on contract manufacturers with suppliers located in India. Still, the point was that all of the big PBM's are currently selling generic statin drugs for really rediculous, marked-up prices right now. Not even Costco had a good deal (they were charging more than $20 for the same quantity of the same drug), so I went with CostPlus Drug Company, and I was satisfied I had made a rational decision.

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