Patients Need to Know the Truth About Medication Coverage Denials

Those of us who have incurable, chronic health conditions such as IBD, diabetes, cancer, heart disease, stroke, etc. have to live with the physical, mental, and emotional aspects of them on a daily basis. The last thing we need is to be told that our medication(s) will not be covered. The added stress of being forced to choose between paying the bills or paying for much-needed treatment is something that we shouldn’t have to worry about.

There are third-party administrators of prescription drug coverage for insurers who are supposed to be pressing for lower costs. However, this is not the case. PBMs (Pharmacy Benefit Managers) use very questionable practices in order to pad their bottom line. Drug manufacturers are given incentives. For example, they will use their brand name medication listed on the formulary given they provide larger rebates over lower-priced medicines. These include biosimilars, specialty generics, or a competitor’s brand. The PBMs then make the decision of how much independent pharmacies will be reimbursed, charge them very high fees, plus control what we’re allowed to have, when/how it will be dispensed to us, and how much we have to pay out-of-pocket.

The FTC (Federal Trade Commission) is currently investigating CVS Caremark, Express Scripts Inc., and other larger pharmacy benefits managers over their unfair and deceptive business practices. An enforced policy statement was issued that will target rebates and fees which can stop competitors from using lower-cost drug alternatives. They have demanded records and documents within 90 days of receipt.  It is also outlined which concessions or prices could be a red flag and potentially result in fines or penalties for these companies.

When we are denied the very thing that will keep our illness from worsening, it can be extremely harmful to us. Do these big PBM organizations really care if a diabetic is hospitalized due to high blood sugar levels? Or whether a physician can administer a newer method of treatment to a cancer patient to get things under control?  Do they really care what will happen to us while we wait for an appeal or cannot fill a script because it’s too darn expensive?

My hope is that the FTC will find “the smoking gun” that they need in order to hold these heartless corporations accountable.  Contrary to what they think, patient lives do matter.