PBMs

[Marvin the Martian]

Indiana looks to take on their expenses to PBMs. Amazingly, Indiana law doesn't require the managers to turn back all of the money they save Indiana. The article says Indiana is one of the few states without that requirement. What the heck?

It in no way makes sense to negotiate with a CVS affiliate to determine what cost CVS will charge as if the affiliate was a neutral broker (just to pick on the CVS /Caremark relationship as an example). There must be a better way.

The company behind the report, RxConnection, LLC, said a contractual loophole called “off-setting language” allows PBMs to keep more money they’re supposed to pay back to the state.​

​

”Indiana is one of the few states that allows this to even happen to begin with, and so that’s an area that definitely needs to be addressed,” State Sen. Andrea Hunley (D-Indianapolis) said.​

https://fox59.com/news/politics/indiana-paid-7-billion-to-pharmacy-benefit-managers-in-five-year-period-according-to-new-report/

 

[Spartans9312]

Indiana looks to take on their expenses to PBMs. Amazingly, Indiana law doesn't require the managers to turn back all of the money they save Indiana. The article says Indiana is one of the few states without that requirement. What the heck?

It in no way makes sense to negotiate with a CVS affiliate to determine what cost CVS will charge as if the affiliate was a neutral broker (just to pick on the CVS /Caremark relationship as an example). There must be a better way.

The company behind the report, RxConnection, LLC, said a contractual loophole called “off-setting language” allows PBMs to keep more money they’re supposed to pay back to the state.​

​

”Indiana is one of the few states that allows this to even happen to begin with, and so that’s an area that definitely needs to be addressed,” State Sen. Andrea Hunley (D-Indianapolis) said.​

https://fox59.com/news/politics/indiana-paid-7-billion-to-pharmacy-benefit-managers-in-five-year-period-according-to-new-report/

I missed this post Marv….PBMs are the devil when it comes to prescription costs.

I know of one guy already retired that graduated pharmacy school in my class.

Guess what he does…..owns a PBM

 

[Marvin the Martian]

I missed this post Marv….PBMs are the devil when it comes to prescription costs.

I know of one guy already retired that graduated pharmacy school in my class.

Guess what he does…..owns a PBM

It seems many on the right and left hate PBMs, why can't we do something about them? In theory, a middleman negotiating lower prices for bulk business could work. But paying CVS to negotiate with CVS seems patently ridiculous.

 

[Spartans9312]

It seems many on the right and left hate PBMs, why can't we do something about them? In theory, a middleman negotiating lower prices for bulk business could work. But paying CVS to negotiate with CVS seems patently ridiculous.

The contracts that the chains are signing are hogwash. Granted, I’ve been out of the contractual end for a decade. But…I’m sure they are no better.

As an example….Pharmacies are reimbursed by a contract that states something similar to: AWP - % + $1

The difference between AWP and acquisition cost on a brand name drug was 18%.

The contracts will be AWP -16% + $1 on the good end…now you used to be able to make good money on generic drugs but they are now subject to MAC (maximum allowable cost).

Now you see why there aren’t many independent pharmacies.

 

[Marvin the Martian]

The contracts that the chains are signing are hogwash. Granted, I’ve been out of the contractual end for a decade. But…I’m sure they are no better.

As an example….Pharmacies are reimbursed by a contract that states something similar to: AWP - % + $1

The difference between AWP and acquisition cost on a brand name drug was 18%.

The contracts will be AWP -16% + $1 on the good end…now you used to be able to make good money on generic drugs but they are now subject to MAC (maximum allowable cost).

Now you see why there aren’t many independent pharmacies.

If CVS makes money on the PBM side, can it afford not to make as much on the pharmacy side? In other words, the PBM subsidizes its ability to sell for less than an independent can.

If we believed competition lowered prices, PBMs wouldn't exist. Insurance companies would come up with a reward system for using lower-cost options.

This leads me to, I just started looking at Part D insurance for Medicare. Those kids out there may not know the Medicare site allows one to put in all one's drugs, and the cost of the drugs will be returned by insurance plan/pharmacy. So, one can decide if saving $15 a month on insurance is cost-effective. I'm not sure why that sort of thing wouldn't work with most people on high-deductible plans by listing the out-of-pocket costs for medicine by pharmacy.

And wow, is Levothyroxine expensive on Medicare. Others have told me their doctors have told them not to use generics, as the QC is bad. I don't know if that is true or just effective marketing, but the cost of Levo is too high to keep using on Medicare.

 

[mcmurtry66]

If CVS makes money on the PBM side, can it afford not to make as much on the pharmacy side? In other words, the PBM subsidizes its ability to sell for less than an independent can.

If we believed competition lowered prices, PBMs wouldn't exist. Insurance companies would come up with a reward system for using lower-cost options.

This leads me to, I just started looking at Part D insurance for Medicare. Those kids out there may not know the Medicare site allows one to put in all one's drugs, and the cost of the drugs will be returned by insurance plan/pharmacy. So, one can decide if saving $15 a month on insurance is cost-effective. I'm not sure why that sort of thing wouldn't work with most people on high-deductible plans by listing the out-of-pocket costs for medicine by pharmacy.

And wow, is Levothyroxine expensive on Medicare. Others have told me their doctors have told them not to use generics, as the QC is bad. I don't know if that is true or just effective marketing, but the cost of Levo is too high to keep using on Medicare.

PBMs obfuscation, lack of transparency, pure evil. Big, big business

 

[Spartans9312]

If CVS makes money on the PBM side, can it afford not to make as much on the pharmacy side? In other words, the PBM subsidizes its ability to sell for less than an independent can.

If we believed competition lowered prices, PBMs wouldn't exist. Insurance companies would come up with a reward system for using lower-cost options.

This leads me to, I just started looking at Part D insurance for Medicare. Those kids out there may not know the Medicare site allows one to put in all one's drugs, and the cost of the drugs will be returned by insurance plan/pharmacy. So, one can decide if saving $15 a month on insurance is cost-effective. I'm not sure why that sort of thing wouldn't work with most people on high-deductible plans by listing the out-of-pocket costs for medicine by pharmacy.

And wow, is Levothyroxine expensive on Medicare. Others have told me their doctors have told them not to use generics, as the QC is bad. I don't know if that is true or just effective marketing, but the cost of Levo is too high to keep using on Medicare.

You’ve got it figured out.

As to Levothyroxine are you sure you weren’t looking at pricing for the capsules?

 

[Marvin the Martian]

You’ve got it figured out.

As to Levothyroxine are you sure you weren’t looking at pricing for the capsules?

Ah, maybe? I will look again, thanks.

 

[Marvin the Martian]

As to Levothyroxine are you sure you weren’t looking at pricing for the capsules?

Thanks, that was it. That makes a huge difference.

 

[Mas-sa-suta]

If CVS makes money on the PBM side, can it afford not to make as much on the pharmacy side? In other words, the PBM subsidizes its ability to sell for less than an independent can.

If we believed competition lowered prices, PBMs wouldn't exist. Insurance companies would come up with a reward system for using lower-cost options.

This leads me to, I just started looking at Part D insurance for Medicare. Those kids out there may not know the Medicare site allows one to put in all one's drugs, and the cost of the drugs will be returned by insurance plan/pharmacy. So, one can decide if saving $15 a month on insurance is cost-effective. I'm not sure why that sort of thing wouldn't work with most people on high-deductible plans by listing the out-of-pocket costs for medicine by pharmacy.

And wow, is Levothyroxine expensive on Medicare. Others have told me their doctors have told them not to use generics, as the QC is bad. I don't know if that is true or just effective marketing, but the cost of Levo is too high to keep using on Medicare.

Eliquis retail cost $511.80 monthly. $6,142 annually.
3 million US users.

Creating $18.4Billion (less programs) revenue annually.

One (1) med.

 

[BadWakeboarder]

Eliquis retail cost $511.80 monthly. $6,142 annually.
3 million US users.

Creating $18.4Billion (less programs) revenue annually.

One (1) med.

I assure you Eliquis does not make $18B annually.

 

[Mas-sa-suta]

I assure you Eliquis does not make $18B annually.

The post said
$18 Billion REVENUE LESS PROGRAMS.

 

[Marvin the Martian]

Eliquis retail cost $511.80 monthly. $6,142 annually.
3 million US users.

Creating $18.4Billion (less programs) revenue annually.

One (1) med.

Medicare must get one heck of a discount. I punched it in and it comes up $47.00 monthly.

Find a Medicare plan

www.medicare.gov

I wonder if that $511.80 is the quoted rate for people with no insurance. I know that Ozempic has a quoted rate of like $900, but just about any plan reduces that to under $100.

 

[Mas-sa-suta]

Medicare must get one heck of a discount. I punched it in and it comes up $47.00 monthly.

Find a Medicare plan

www.medicare.gov

I wonder if that $511.80 is the quoted rate for people with no insurance. I know that Ozempic has a quoted rate of like $900, but just about any plan reduces that to under $100.

The post said retail.

 

[BradStevens]

It seems many on the right and left hate PBMs, why can't we do something about them? In theory, a middleman negotiating lower prices for bulk business could work. But paying CVS to negotiate with CVS seems patently ridiculous.

A once wise poster had a good saying for this.

If you allow government to be bought . . .

 

[Marvin the Martian]

A once wise poster had a good saying for this.

If you allow government to be bought . . .

This raises a great question, why shouldn't we eliminate super PACS? I am sure some of the people who complain the loudest about the government being bought are some of the people who vehemently opposed campaign finance reform.

Cut out PACS. . Anyone who sits on a committee with oversight of an area cannot go to work in that area for 5 years without a massive penalty. Same for anyone in an agency with oversight, no more leaving the FDA to lobby the FDA for a drug company (at least not in 5 years). There are a lot of other crackdowns. Corporate foundations tend to give money to charities with politicians on the board. Hmmm, I wonder why.

How Corporations Use Charitable Giving to Wield Political Influence

Companies spend almost three times the amount on politically motivated charitable giving than they spend trying to influence politicians through PACs.

www.chicagobooth.edu

Of course, as that points out, reducing PAC money just results in more money going underground somehow. So it is a bit of a conundrum other than the obvious. Everyone polling over $X gets $Y of government funding and that is it, no additional money is allowed. Not even personal money. It would have to be indexed so Paducah gets less than Frisco, just a cost of doing business thing. Then tax money going to PACS that can be used "independently". I might want to give $500 to a PAC, but if I had to pay $100 in tax then maybe I only give $400. That cuts down on their value.

Just ideas, not sure I believe any of them. But if we don't want government bought, we need solutions that reduce money. Something we have needed for a long time, but you know, Citizens United.

 

[BadWakeboarder]

The post said
$18 Billion REVENUE LESS PROGRAMS.

Why not say $69B less “programs!” It’s just as accurate.

BMS reports on Eliquis revenues in their 10Q and 10K. 2023 was $12B. It’s not going up 50% this year.

It’s not “programs”, it’s adherence and other variables that bring it down.

 

[Mas-sa-suta]

Why not say $69B less “programs!” It’s just as accurate.

BMS reports on Eliquis revenues in their 10Q and 10K. 2023 was $12B. It’s not going up 50% this year.

It’s not “programs”, it’s adherence and other variables that bring it down.

Pfffft!
Only $12billion...
A pittance really.

 

[Spartans9312]

Pfffft!
Only $12billion...
A pittance really.

Eliminate PBMs and the price to the consumer drastically reduces.

 

[mcmurtry66]

Eliminate PBMs and the price to the consumer drastically reduces.

I believe that’s Cuban’s aim. But what’s the rub? If you go it alone you’ll have a limited formulary? Cuban can’t manufacture everything for a host of reasons

 

[Spartans9312]

I believe that’s Cuban’s aim. But what’s the rub? If you go it alone you’ll have a limited formulary? Cuban can’t manufacture everything for a host of reasons

I have not looked at Cuban’s business at all. So I can’t speak to that.

If the customer was paying up front for their eliquis and having to submit for reimbursement from their insurance….the price would come way down.

To use Mas’ numbers….there aren’t a lot of people able to fork out $500+ a month and if your on Eliquis you’re also on other meds

 

[BradStevens]

I believe that’s Cuban’s aim. But what’s the rub? If you go it alone you’ll have a limited formulary? Cuban can’t manufacture everything for a host of reasons

Didn’t Dimon and Bezos team up to try to solve this? If those two couldn’t figure it out, what hope for we mere mortals?

 

[mcmurtry66]

Didn’t Dimon and Bezos team up to try to solve this? If those two couldn’t figure it out, what hope for we mere mortals?

Not sure

 

[JamieDimonsBalls]

Indiana looks to take on their expenses to PBMs. Amazingly, Indiana law doesn't require the managers to turn back all of the money they save Indiana. The article says Indiana is one of the few states without that requirement. What the heck?

It in no way makes sense to negotiate with a CVS affiliate to determine what cost CVS will charge as if the affiliate was a neutral broker (just to pick on the CVS /Caremark relationship as an example). There must be a better way.

The company behind the report, RxConnection, LLC, said a contractual loophole called “off-setting language” allows PBMs to keep more money they’re supposed to pay back to the state.​

​

”Indiana is one of the few states that allows this to even happen to begin with, and so that’s an area that definitely needs to be addressed,” State Sen. Andrea Hunley (D-Indianapolis) said.​

https://fox59.com/news/politics/indiana-paid-7-billion-to-pharmacy-benefit-managers-in-five-year-period-according-to-new-report/

What's your take on this Brookings review of the PBM debate, which implies there are opportunities to improve the PBMs, but that even if you extract them from the equation, things shift dramatically?

A brief look at current debates about pharmacy benefit managers

Matthew Fiedler, Loren Adler, and Richard G. Frank explain the current debate on PBMs and qualify the proposals being considered in Congress.

www.brookings.edu

 

[Marvin the Martian]

What's your take on this Brookings review of the PBM debate, which implies there are opportunities to improve the PBMs, but that even if you extract them from the equation, things shift dramatically?

A brief look at current debates about pharmacy benefit managers

Matthew Fiedler, Loren Adler, and Richard G. Frank explain the current debate on PBMs and qualify the proposals being considered in Congress.

www.brookings.edu

I think the article points out a strange issue we face as a nation. It is suggested that without keeping part of the rebate, PBMs won't negotiate aggressively. That is like Brad being my lawyer and when it is our turn to present saying, "I am not receiving a rebate on this, so we are not presenting a defense."

If a company is paying a PBM, the PBM has a responsibility to do its best to represent that client. That is why the real estate world just got turned upside down by the courts, many agents forgot they were required to work in the best interest of the client.

I don't have a good answer on restricting costs with or without PBMs. To an extent, the Wal*Mart model of "give us this deal or we won't put your product on the shelf" doesn't work with drugs as people must have them to live. I am not sure why, as a whole, CVS or Walgreens, can't negotiate on their own. If CVS can sell a drug cheaper than WalMart it would be a big selling point to insurers and customers.

In other words, this whole thing that 10 people go in and get 10 different prices is a problem. We don't do that with gasoline, milk, shirts, or most other manufactured products.

 

[BradStevens]

Not sure

+ Buffet

Column: That Buffett-Bezos-Dimon healthcare venture goes bust — predictably

Warren Buffett, Jeff Bezos, and Jamie Dimon thought they could solve healthcare. They never had a chance.

www.latimes.com