Resources on Express Scripts/Copay Maximizers/Pharmacy Steering?
I work for a large (national) non-profit that has put together a task force to review its health plans. The task force is having a Zoom meeting and I signed up to speak. I’ve been extremely happy with the health plan except for Express Scripts. The practices I’ve had problems with:
The copay maximizer. I was required to enroll in one in order to get a medication filled. The copay maximizer would have required me to enroll in the patient assistance program, but the assistance program terms prohibited the use of a copay maximizer. I ended up getting another drug.
Pharmacy steering. I’ve got a problem with them requiring use of their own pharmacies in part because of the damage to local business and patient choice. And for the specialty med, the packaging waste is obscene and would not be necessary if I purchased locally, plus the inconvenience of having to take time off work in order to be home for deliveries.
Lack of transparency. When I was choosing a specialty med, they would not provide any information about coverage for the class of medication I needed. I wanted to choose the cheapest drug (both for my oop and for the plan), and I had to research the drugs on my own to get a list and then enter each drug individually into the search tool.
Overly burdensome PA/step therapy. I understand all plans do this and it often makes sense. To get approval for the specialty med that cost $6000, I had to try a drug that cost $10. I’ve got no problem with that. I was recently denied a claim for a generic drug that cost less than $10, and I really think in this case the requirements were just designed to deter the patient and get them to pay cash. It’s a common medication and was prescribed for its FDA-approved indication. They required a PA and step therapy. Even though I’ve already met my oop max, I just paid cash for it so my doctor wouldn’t have to do the extra work. My mind is blown that they would deny a $7 medication claim on a plan with an $1100 premium.
Anyway, these are the concerns. The plan is self-funded and the organization is mission-driven, so they do care about justice and not just money. It a religious organization and is exempt from ERISA; however, they are currently in compliance with the law and sometimes exceed legal requirements (ex – dependents can stay on until age 30 and the employer pays 75% of the premium).
I would like to find resources that elucidate the ethical issues with PBMs, because I think that’s most likely to influence the task force. Any help would be much appreciated.
