Two years ago, I made a very well-informed decision to simply bypass our own healthcare insurance for a number of prescriptions used in my household because we were paying out-of-pocket until the deductible was satisfied anyway (which was about half the year), and our new insurance carrier Aetna and its PBM Caremark was obviously ripping us off by a fairly wide margin. In fact, the financial gamesmanship (or as the PBM's call it, "Price Arbitrage") was so overt, that it would have been financially foolish to stick with insurance under the presumption that it contributed toward satisfying the deductible (a falsehood; they only credit people for the PBM-negotiated price, not the artificially-inflated cash prices patients are actually charged). Bypassing our insurance saved us 56%, 70%, 75%, and 82% on a number of drugs (most of which were generics anyway, and generics which are supposed to be inexpensive, but Caremark was overcharging us by a wide margin on every one of those drugs).
Initially, my tactic was to find discount coupons powered by PBM's who offered lower prices, but it was almost always from a different PBM than the one used by our own insurance company. That worked reliably for several years. But by 2022, we started to experience some random, unexplained (and illogical) price increases on generic drugs. Then, I knew I was being gamed, so I widened my search, and was successful although it took even more work.
First, a random price-increase happened with the generic statin drug (formerly sold by AstraZeneca as Crestor). That particular drug, known generically as rosuvastatin calcium 10 mg tablets, had previously been purchased from United Healthcare Group's OptumRx PBM unit by using an OptumPerks coupon and using Optum Store. Recall that my carrier was Aetna (owned by CVS Health, which also owns/operates the PBM known as Caremark). My insurance carrier Aetna/Caremark/CVS Health was charging us $33.84 for a 90-day supply of the statin drug, and we were paying for it completely out-of-pocket for about half the year, so it was a clear money-saving move to simply bypass our insurance. By cutting Aetna/Caremark/CVS out of the transation, I saved 56% on the drug until June 2022. Then, in June 2022, Optum indicated in my purchase history that while I'd previously paid $15 for a 90-day supply of generic Crestor for an entire year, but the "new" (and not publicly announced), higher price had jumped by 40% to $21 instead. Since I had no refills after that, and $21 was still cheaper than $33.84 that Aetna/Caremark intended to charge me for the drug, I paid the new, higher price, only I vowed to find a new source for it.
My spouse also relies on a few generic drugs, including one used to treat hypertension, as well as several different eye drops which are used to manage glaucoma. On the eye drops, prices of those drugs are insanely costly for almost no product; the bottles are even tinier than a 10 mL bottle of insulin; being sized from about 2.5 mL to 5 mL, and yet the prices range from $17/bottle to $78/bottle. Yet all but one of the eye drops is a generic product, and the pharmacy changes the suppliers all the time (sometimes they come from Alcon [owned currently by Novartis Sandoz unit, though its being spun-off as a standalone company to be called Sandoz set to close during 2H 2023], other times they come from Pacific Pharma/Allergan, or Oceanside Pharmaceuticals/Valeant Pharmaceuticals. We've even received one bottle from a previously unidentified India-based pharmaceutical company. The quality of the eye-dropper bottles varies widely - some are not great quality and lead to wasting the content contained in the bottles themselves), but the point is that they are generic products which nearly any company can make except prices are ridiculous.
Curiously, the hypertension drug known as Eplerenone 50 mg tablets (previously sold under the brand-name Inspra) was selling from Aetna/Caremark/CVS for $48.40 (even after satisfying the deductible) for a 30-day supply which seemed very high for a generic pill. Initially, we used a coupon from InsideRx (InsideRx is owned by Cigna's Express Scripts PBM business known as "Evernorth"), which resulted in additional savings of $10.00 off the price we were charged for the drug at CVS (that also meant that TWO PBM's were involved in the transaction; Caremark which was our insurance company's PBM, as well as Express Scripts which powered the InsideRx coupon), so the revised total became $38.40 for 30 tablets which is no bargain for a generic drug. That still worked out to a cost of $1.28/tablet which is no bargain for a generic, but at least that enabled us to buy it with the existing refills we already had at the pharmacy, only getting a discount. However, Express Scripts Cash-Pay Mail Order Pharmacy by InsideRx's price for the same generic drug was just $8.72 for a 30 day supply! We opted to buy a 90-day supply of tablets for $25.39. Naturally, Cigna's Express Scripts self-preferenced its own mail order pharmacy over other pharmacies within its own retail pharmacy network; doing so maximizes its own profits.
To the best of my knowledge, the Express Scripts by InsideRx was "powered by" the PBM's National Preferred Flex Formulary, which tends to favor drugs with lower list prices over the high-list/high-rebate versions of drugs, rather than Express Scripts' much-bigger National Preferred Formulary (NPF) which happens to be Express Scripts' largest commercial formulary (that formulary reportedly covers more than 28 million covered patient lives) which tends to favor high-price/high-rebate drugs. Its obvious why that's their biggest formulary; it creates more opportunity for spread pricing derived from heavily-rebated brand-name drugs. Still, it had self-preferenced its own mail order pharmacy over other pharmacies in its network.
To patronize Express Scripts Cash-Pay Mail Order Pharmacy by InsideRx, they imposed a number of consumer-unfriendly policies which forced patients to have their doctors only e-prescribe drugs (no paper scripts were accepted), and they also required auto-billing to a credit card, so it wasn't the most consumer-friendly option. Still, the prices were 82% cheaper than our own insurance was, making it a smart decision.
At least that was the case until now.
But we received a peculiar letter this week.
The letter was dated October 24, 2022, although they likely used the cheapest possible form of direct mail (sending it third-class to minimize the postage expense) so it arrived sometime between Monday, November 14, 2022 and Saturday, November 19, 2022 (we were traveling to Iceland when it arrived, so I'm not certain exactly which day the letter arrived).
But now it appears as if they are trying to discontinue cash-pay orders via InsideRx.
Maybe Express Scripts Cash-Pay Mail Order Pharmacy by InsideRx found that cash-payers were a hassle to deal with? I can only speculate.
I wasn't personally using Express Scripts for any of my own personal prescriptions, but my spouse had several scripts auto-filled with Express Scripts Cash-Pay Mail Order Pharmacy by InsideRx because their prices were lowest, but we had very marginal interaction with Express Scripts.
It began when we mailed a letter to the doctor last year and asked them to send an e-script into Express Scripts for a few prescriptions, which were billed to a credit card, and that was the extent of the interaction.
Apparently, Cigna's PBM unit known as Evernorth, which operates Express Scripts as well as the prescription drug coupon-generating website/app were FORCED to mail an old-fashioned letter to us because of their electronic-only policies designed to maximize the revenue of Express Scripts at the expense of patients doesn't really enable direct-to-patient communications. The letter was required because patients aren't likely to pay cash to Express Scripts Mail Order Pharmacy anymore.
As for what we'll end up doing, I think we'll simply switch suppliers when the refills are used up.
We discovered it was actually cheaper to buy generic Crestor (rosuvastatin calcium 10 mg) tablets from the startup known as the Mark Cuban Cost Plus Drug Company (see my post at https://blog.sstrumello.com/2022/08/generic-crestor-pricing-insanity.html for more). It was reliable and sold at a fair-price; and the company has actually been known to reduce its prices when their own costs fall. Their margins are fixed at 15% (enough to keep the business going) on every drug it sells; plus a $3 pharmacist fee and another $5 for shipping. Still, even with the $8 ($3 + $5), the price was still cheaper than the PBM's were charging for the same drug.
Not only that, but the Mark Cuban Cost Plus Drug Company anticipates it will be selling some 2,000 drugs (or more) by the end of 2022, and it's finally started selling a few branded products such as Roche Accu-Chek blood glucose testing supplies at prices which are lower than almost anywhere else. In fact, I have found the prices are so low that they're possibly even cheaper than some of the generics which work in the old OneTouch Ultra meters (truth be told, I did find Unistrip1 strips a bit cheaper, and many retailer private-label test strips work adequately for many people's needs, and those sell for less cash).
The Mark Cuban Cost Plus Drug Company also sells some eye drops, including Brimonidine Tartrate for glaucoma, but the size is 15 mL instead of the 10 mL which means with Mark Cuban Cost Plus Drug Company, we receive 50% more medicine at roughly the same price. I also found their prices on a 90-day supply of eplerenone 50 mg tablets to be $27.30 compared to the price of $25.39 we got from Express Scripts Cash-Pay Mail Order Pharmacy by InsideRx. Admittedly, it is slightly more costly than we attained via Express Scripts Cash-Pay Mail Order Pharmacy by InsideRx, but is still vastly cheaper than the price of $48.40 Aetna and Caremark intended to charge us for only a 30-day supply of the same medicine.
Above all, my feeling about doing business with the Mark Cuban Cost Plus Drug Company is that the prices are honest and it feels like patients are getting a fair deal. By comparison, PBM's are gaming the system to their own benefit at every opportunity, and they are doing so mainly by withholding information.
Incidentally, Mark Cuban Cost Plus Drug Company is currently trialing insulin sales, perhaps the prescription best known for egregious spread pricing pocketed by PBM's and overt patient ripoffs. It is very much a trial right now. Details on the trial can be seen at https://costplusinsulin.com/.
If your doctor his not participating in the Cost Plus Drugs' insulin pilot program, you are not currently eligible for this test and your prescription will not be filled. But they are selling a 90-day supply of the unbranded Lilly Insulin Lispro U-100 (the "authorized generic" version of branded Humalog). Patients' doctors must be a part of the trial. Its shipping and handling fee is $65 per order.
The company says because its cold shipping containers can only hold up to a certain amount of insulin, the trial is only supporting orders up to the following quantities per order:
- 12 vials of Insulin Lispro
- 8 packs of Five Insulin Lispro KwikPens® (40 total KwikPens®)
If patients in the insulin trial attempt to order more than 8 packs of KwikPens® or 12 vials, their order will be automatically cancelled. It's a trial, after all.
But of note, the total price for a 90-day supply of insulin is $170. The total price includes fulfillment, packaging and shipping. There may be incremental cost for shipments to Hawaii and Alaska.
The company acknowledges that for patients that only use 1 vial of Humalog per month, the Mark Cuban Cost Plus Drug Company insulin price in the trial works out to a price of $56.67/vial, which is actually HIGHER than the company wants it to be.
That said, any patient can freely download a Lilly manufacturer coupon and buy the unbranded, "authorized generic" version of Humalog for $35/vial. Coupons can be downloaded instantly at https://www.insulinaffordability.com/. Rival Sanofi also sells a biosimilar of Humalog branded as Admelog, and patients can also download a manufacturer coupon from Sanofi at https://www.teamingupfordiabetes.com/sanofidiabetes-savings-program/ (they can also use Sanofi's proprietary prandial insulin analogue known as Apidra for the same price of $35/vial) from local pharmacies and chain pharmacies around the country.
Right now, all of these are for prandial insulin analogues, but none are for basal analogues. That said, the Sanofi ValYou coupon will work on Lantus as well as the unbranded "authorized generic" version of Lantus known as Winthrop US Insulin Glargine Injection U-100, which makes it possible to buy both basal and prandial insulin analogues at a price of $35/vial today.
To catch some of my prior blog posts related to this subject, see:
https://blog.sstrumello.com/2021/11/how-we-wrested-control-of-our-rx-drug.html
https://blog.sstrumello.com/2021/09/coupons-pbms-oh-my.html
https://blog.sstrumello.com/2022/07/turning-pbm-arbitrage-on-its-head.html
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