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PBMs and their relation to FEHBP: “There’s a good chance we’re not getting a good deal…We can’t find out information such as the incentive pay, rebate pay, volume discount pay, administrative fees of PBMs. We can’t find that information out, because we can’t audit that; it’s not available to us now.”11 As a result, PBMs are making tremendous amounts of money by hiding the real price of the drug and charging patients – and ultimately, even if indirectly, the taxpayer – an absurdly marked-up rate. Mail order problems Conventional wisdom suggests that ordering prescriptions through the mail is a win-win for all parties involved. This assumption is furthered by the contention that mail-order delivery, by its very definition, means that patients have the convenience of receiving their medicines literally at their front door. Another misconception is that mail-order delivery will cut down on the costs of government-provided health insurance. With this is the expectation that the tax dollars spent on these programs will be used properly and in a transparent matter. Unfortunately for taxpayers and patients, mail-order delivery contributes much more to burden them than it provides any benefits. The government is beginning to raise concerns about mail order waste and abuse. In April 2013, the Centers for Medicare and Medicaid Services released its final Call Letter to all Part D plans for 2014. In it the agency raises the issue of waste and added costs from automatic fills and refills by mail-order companies/PBMs when it noted that, “In a related issue, CMS has received complaints indicating that some mail-service pharmacies automatically deliver new prescriptions that were phoned in or e-prescribed from the physician’s office without confirming that the patient wants the prescription filled and delivered.  As a result of automatic delivery practices described above, CMS has received complaints that beneficiaries have had medications delivered that had been previously discontinued or were otherwise unwanted and unnecessary at the time of delivery… Consequently, automatic delivery practices are potentially generating significant waste and unnecessary additional costs for beneficiaries and the Part D program overall. While proponents of these programs tout improved adherence, it remains unclear to us that they can provide evidence of actual improvement in adherence, or that permitting such programs to continue without reorder confirmation is cost-effective.”12  CMS will now be requiring consent for each prescription fill or refill prior to delivery beginning January 1, 2014. Many problems exist with mail-order prescriptions, most of which involve logistical issues. Other problems inevitably result when something is placed on auto-pilot with little to no supervision, as the mail-order delivery system frequently is. For example, if the patient is unhappy with the service and wants to cancel, the steps to do so are far more difficult than merely picking up the phone.13 In fact in some instances, it could even cost a consumer more to cancel the drug delivery than the cost the consumer bears by continuing to receive a medication that he/she does not need. With unwanted and unneeded medicine piling up in the home, the medication must be disposed somewhere and by someone. Community pharmacists are often the ones charged with the expensive task of doing just that. Another issue arises with the mode of delivery. Depending on the U.S. Postal Service as the party responsible to distribute prescriptions poses many problems. The inefficiencies and shortcomings found in the nation’s postal system contribute significantly to many of the problems found within the mail-order prescriptions. For 11. Parker, Alex M. “Lawmaker Pledges More Oversight of FEHBP Drug Costs.” - Pay & Benefits. Government Executive, 25 June 2009. Web. 01 Feb. 2013. <http://www.govexec.com/pay-benefits/2009/06/lawmaker-pledges-moreoversight of-fehbp-drug-costs/29436/> 12. United States Department of Health and Human Services, Center for Medicare Services, April 1, 2013, “Announcement of Calendar Year (CY) 2014 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter,” http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/ Downloads?Announcement2014.pdf. Page 144. 13. NCPA document, titled “Pharmacy Benefit Managers: Mail Order Services 101” 22


40113 ChoiceRx ePub long (1)
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