The views stated here are those of the author and do not necessarily reflect those of the editors of this newspaper. We welcome supporting or opposing views on any published item. Received November 8, 2023.
2023-2024 is again a year of incredible changes.
Pharmacy Benefit Managers, or PBM’s, who were supposed to have saved all of us money, have again worked to increase deductibles, decrease covered medications, and decrease patient access to a pharmacy of their choice through copay inducements, or by only reimbursing a pharmacy below cost to make participation impossible.
This year, Express Scripts, which is the Pharmacy Benefit Manager (PBM) for Cigna Medicare Plans, had the audacity to tell me they are lowering reimbursement to Nutmeg Pharmacy and Nutmeg should be happy they are bringing clients to our store.
Express Scripts has extended Nutmeg Pharmacies a one- sided, take-it-or-leave-it contract offering us well below cost reimbursement, while expecting us to remain open twelve hours a day for your care and convenience. This is not viable, and we will not be taking their contract.
We certainly cannot pay staff, pay taxes, contribute to the community and work below cost, never mind discounted rates.
Do PBM’s like Express Scripts, which also run their own mail-order pharmacies, care that you need an antibiotic at night or over the weekend? Where are these mail order pharmacies when you need your vaccinations?
What is interesting in our great state is that there are minimum prices for alcohol and cigarettes, but these PBM’s can offer below-cost reimbursement for your healthcare. The State of Connecticut just passed legislation that guarantees protections against fiduciaries that cause exploitation of seniors. I submit that these PBM’s are exploiting seniors by restricting access to pharmacies of their choice, depriving seniors of specialized packaging, delivery, and of the ability to discuss their medication profile with a professional they trust.
Please realize that just because the pharmacy is reimbursed below cost, it doesn’t mean the government is paying less for your prescriptions. It just means Express Scripts is making more. Express Scripts makes a significant amount of money for the insurer (Cigna) they work for by extracting 30% of the cost of your brand-name prescriptions from the manufacturer. This sum is significant. With the average brand-name prescription costing more than $345 per prescription, this means that Express Scripts is earning more than $100 per prescription for Cigna from you. It is not hard to see why Cigna paid $67 billion for Express Scripts.
If the manufacturer doesn’t pay, then the drug your doctor prescribes will not be on the formulary, or it will be on at a much higher co-pay.
This is awful, and it results in all drugs costing more. What would you do if you were the manufacturer? You would do what is happening: the cost of brand-name prescriptions is going up to make up for what the PBM is taking for your insurer. So, the PBM’s are actually increasing the cost of your healthcare.
When you increase the cost of the drug on the formulary, and you penalize the client whose drug is not on the formulary, the PBM has not done its job.
More to follow on all this, as we need to get our federal lawmakers on our side. Why should it take until 2026 to get drug pricing under control? We have to start watching the money flow. You cannot be voting on issues as critical to the population if they have a financial interest in the outcome.
Our legislators have a difficult job; doing the right thing is hard. Please call them, let them know you are aware of what is happening, and that you need them to address this. Solutions can happen now, not in 2026. We all can have quality healthcare when we stop these atrocities.
Medicare Open Enrollment closes on December 7, 2023. Please schedule a time with your local Nutmeg Pharmacy to review your prescriptions and let us help you understand all the prescription insurance choices you have.
Greg McKenna, Nutmeg Pharmacy, Higganum