Pharmacists: Partners in Health
If a health insurance executive can't figure out how deductibles work, who can? Your pharmacist.
A little over a month ago, Wendell Potter penned an article detailing his experience getting Symbicort on his Medicare Part D Plan. I’ll note here that Mr. Potter is a former Cigna executive who wrote personally wrote lobbying talking points to get Medicare Part D into law. He complained that his plan had him pay $606 out of pocket for a 3 month supply of Symbicort (picked up at what I assume was a CVS). As a result, he went through a whole lot of trouble involving his physician, GoodRx, and an overworked Rite Aid pharmacist only to learn that Wixela cost $141 for a 3 month supply on his Wellcare plan. He saw this as a minor victory as $141 is a lot less than $606.
Here’s the fun part - he could’ve saved himself a whole lot of time and effort if he had come to Jolley’s (or another independent). His receipt would have looked something like this:
He (with a little help from myself or my staff) would have been able to determine that his $606 out of pocket cost happened to include a deductible. With a little effort, I would have told him that $480 of his cost was covering his deductible, and that the subsequent fill would have been $126 for a 3 month supply, not $606 in perpetuity. In actuality, he would’ve paid $621, not $606, because Wellcare Value Script doesn’t allow independent pharmacies in their “preferred network” (preferred networks are about cost, not quality). I think the marginal $15 would have been well worth not going through the rest of the effort he put himself and his physician and a second pharmacist through.
Medicare Part D plans are ridiculously complex to a layperson, and Mr. Potter’s plan is a case in point. Wellcare Value Script PDP has 5 drug tiers, 2 pharmacy tiers (preferred and standard), and a deductible that only goes into effect for tier 3, 4 and 5 medications. Medicare drug benefits have 4 phases: deductible, initial coverage, donut hole and catastrophic, resulting in varying out of pocket costs depending on the pharmacy used, the amount of money already spent, and the drug itself throughout the year. His Symbicort prescription cost him $606 because he had to pay that $480 deductible (which only kicks in on the first “preferred brand” or higher cost drug in the year) and then he had to pay 3 months of $42 copays because he was at a preferred pharmacy ($480 + $42*3 = $606). He later got Wixela for $141 at a Rite Aid, which is 3 months ($47 each) of a tier 3 item without the deductible at a standard pharmacy. If he hadn’t picked up the symbicort first, the Wixela would have cost him $621 at the rite aid, because he hadn’t paid his deductible yet ($480 + $141 = $621). Later in the year, he may find that he’s hit the donut hole, when his cost would shift to 25% of the total cost of the medicine (~$257 out of pocket based on NADAC for 3 months of Symbicort and ~$136 for 3 months of Wixela).
If he had asked, I would have been able to tell him about Wixela’s much lower total cost vis a vis Symbicort (which wouldn’t affect his out of pocket until the end of the year when he wouldn’t reach the donut hole with Wixela where he would have with Symbicort). In all honesty, if I were the pharmacist checking his prescription, I probably would have suggested it without being asked, because Wixela is generic and Symbicort is brand, and there is no pharmacy profit in branded drugs anymore (see this lawsuit which found that a pharmacy paid 150% of their profit margin to CVS’s SilverScript Part D Plan in DIR fees, resulting in a net loss - HIV drugs are mostly branded).
Here’s my recommendations for Mr. Potter (and anyone else who finds themselves paying large sums of money for their medications):
Use an independent pharmacy. Independent pharmacies consistently staff more people than the CVS and Rite Aid that Mr. Potter visited, and consistently get much higher customer service ratings than chains. That little bit of extra staff makes a big difference in the pharmacist’s ability to take the time to talk to you.
When you have a drug cost problem, talk to YOUR pharmacist FIRST. This requires that you have a personal relationship with a pharmacist (and preferably you get all of your medications in one place). If you are taking medications regularly, you should have a pharmacist who knows you and knows what drugs you are taking. Community pharmacists know a whole lot more about drug costs than physicians, who mostly rely on GoodRx just like Mr. Potter did. GoodRx isn’t a pharmacist, and they’re a poor substitute for one in a chain-dominated world. Talk to your pharmacist first, and you may not need to bother your physician for more than a signature approving the pharmacist’s recommendation of drug therapy changes.
Make an appointment with your pharmacist for a time when it’s less busy. This avoids the line that Mr. Potter caused. (Sidebar: pharmacies need to make it a lot easier for patients to book one-on-one time with their pharmacist, and should charge for that time).
If you are on Medicare, talk to your pharmacist about Medicare Part D Plans during open enrollment. While exceptions definitely exist, most insurance brokers hardly know what a formulary is, let alone the difference between Steglatro and Jardiance. Community pharmacists are much better equipped to help you sort out the myriad of plan options (57 options in my area). This past year, I helped a patient to change plans from the Medicare Advantage plan his agent recommended 10 years prior as the “best plan” (with a $110/month premium) to a Medicare Advantage plan with a $0/month premium. His copays dropped dramatically as well.
While this almost certainly doesn’t apply to Mr. Potter, look into the Low Income Subsidy (aka Extra Help). If you qualify, you can literally pay $4 for 3 months of Symbicort or other brands instead of Mr. Potter’s $606.
In short - the missing piece in Mr. Potter’s experience was a personal healing relationship with a pharmacist. You can’t get that kind of relationship from “Canadian” importation (caveat emptor) or from a mail order pharmacy. Pharmacy Benefit Managers don’t value those healing personal relationships, and neither do status quo Part D Plans; they just see numbers on a spreadsheet. (exceptions exist!)
In some ways I blame my profession for this failure - by and large pharmacists don’t charge for their time and don’t have a workflow that facilitates appointments (except maybe to get a COVID vaccine or a flu shot). But I also blame our politicians who decided that pharmacists were cool enough to be required to counsel Medicaid patients, but didn’t think that counseling should be paid for.
At a recent conference, my friend Dr. Kathy Campbell, shared this image of the 1972 commemorative Pharmacy Stamp.
In the bottom left corner, you’ll notice that it says “Partners in Health.” I think that since 1972, a large part of the population has lost the perception of pharmacists as partners in health (I’ll note that PBMs controlled less than 5% of the market at the time). But that is still what pharmacists are. We partner with you to help you obtain your medications, even through shortages. We ensure that your medications are working for you. We help you minimize adverse effects. We try to get you off of them whenever possible (every single pharmacist that I’ve ever spoken to wants to help people take as little medicine as possible to treat and control disease, and not a tablet more). We can help you figure out how to reduce your costs for medications. We can help you decipher your rube-goldberg-machine-esque benefits (which are apparently too complex for an insurance executive to decipher on their own). There is literally no one else in the system who is better at this than a community pharmacist. You need a partner in health. Make sure that you have a personal pharmacist who knows you and knows all of your medications. Don’t treat your health journey like a coupon cutter treats getting groceries–going to 5 different pharmacies in search of the lowest price on GoodRx. Find a pharmacist who will partner with you in your health journey, and use their pharmacy consistently. It’s worth it, I promise.
Ben, I got so upset when seeing the Harvard study showing Cuban Cost Plus saving CMS $!!! Cuban apparently inventing a miracle solution to the drug cost problem is a whole different story! But why everyone keeps thinking that 30 day or 90 day supply of pills is similar to a Walmart 30 day worth of mouthwash or Costco 90 day worth of mouthwash jugs?! Who the heck is responsible if the drug is not dispensed correctly, or possible clinical interactions exist, etc.? You want us to be liable if anything goes wrong but don’t want to compensate us for that work!!! We have come to a point where significant population has been trained by PBMs that they don’t have to see a pharmacist. I heard one of the guys I met on the pickleball court bragging that he hadn’t seen a pharmacist in ages! Are we (pharmacists) all going to wait the pseudo free market laissez-faire to work its way out to see who is still standing? The pickkleball guy should be paying a $50 dispensing fee when he goes to a retail pharmacy with a prescription from an ER but that’s not happening! Because the ER chain that got recently bought out by a NY private equity group wants to dispense all the drugs at cost to milk the maximum $ on the backend for the ER visit! Until every prescription dispensed is guaranteed with dispensing fees that commensurate with pharmacy expenses and inflation, it is going to be tough! Why can’t NCPA run a coherent national campaign on TV and social media to promote our services?
Very good Benjamin! We just need to bottle it and sell it to the powers that be. Keep up the great work.