NCPA, consumer advocates and others oppose the proposed merger of pharmacy benefit managers (PBMs) Express Scripts (ESI) and Medco for fear that it would reduce competition and patient choice while increasing prescription drug costs. Some recent complaints voiced by patients and/or their community pharmacists sum up what appear to be common problems with the PBM ‘status quo’—issues that likely wouldn’t improve and arguably would grow worse if these two entities are allowed to become the mega-PBM envisioned by the merger.
The comments we’ve heard center around three issues: patient problems with ESI-Medco mail order pharmacies, below-cost reimbursement and questionable auditing of community pharmacies.
A combined ESI-Medco PBM with almost 60 percent of the mail order market would face even greater incentive to push patients to its proprietary mail order facilities (and, in Medco’s absence, less competition-driven pressure to improve service). With the clout of more “covered lives,” there’s little to stop ESI-Medco from offering more below-cost contracts to pharmacies that want access to those patients, or from delaying updates to reimbursement rates when drug costs spike (and keeping the difference). Regarding auditing, the merged entity would have even less motivation to correct auditing practices that are perceived by community pharmacists as abusive and undermine their ability to compete with ESI-Medco mail order facilities.
Here is a compilation of just some of the problems with the two PBMs expressed to NCPA this year or in late 2011:
- A lot of times some of these patients that use the mandatory mail order come to my pharmacy asking questions about some of their medications and complain about the difficulty they encounter calling Medco or ESI. Other times, they run out of their medications and have to come in requesting for a few pills until their orders come in the mail.
- ESI audits every refill for one of my prescriptions. Often it is the same ESI technician auditor who is responsible, and every time the prescription passes the audit, but it still means every month when this customer gets their refill, I have to set aside time to do all of the ESI audit paperwork and fax it in to them. For this patient, this medication is a medical necessity, and even though we lose money on every refill because of the time it takes me to respond to the unreasonable audit every month, I do it because this patient needs this medication to maintain a fairly normal quality of life.
- I was audited by ESI last September. I was penalized heavily for clerical errors, even when I demonstrated to them our honest mistakes didn’t lead to any overpayment on claims.
- ESI constantly underpays many prescriptions as they do NOT update prices in a timely fashion. I update on a daily time frame, but it seems like they are ALWAYS 30 days behind. They will NOT go back & correct the payments.
- We try to work with ESI & Medco to update them on manufacturer price increases in a timely manner. The in-house data base is not kept up to date especially with drugs that they MAC [i.e., to which they apply a maximum allowable cost or MAC limit]. The MAC committees have no time schedule to meet so price increases take up to 60-90 days while stores are expected to fill prescriptions, many times at a loss. The pricing guides show prices from manufacturers that have stopped manufacturing the product without showing the plans this information – so PBMs continue to use old pricing in their calculations.
- When an AWP[average wholesale price]/acquisition cost is increased, ESI is slow to update their files, and when they are updated, the pharmacy is not allowed to re-bill the claim at the correct price. MAC prices on TRICARE prescriptions are abusively low.
- This March I temporarily lost a patient because Medco called her and asked her about using mail order. She said no but a few weeks later she got home from running errands and found a box of medication on her porch. This occurred in June in Oklahoma when the temperatures were in the high 90s every day and we do not know how long they were there because she does not regularly use her front door. Medco refused to take them back so she had to use them hoping the heat had not damaged them and she could not afford not to. This patient has had multiple strokes and a myriad of other health issues. Each month she brings her Rubbermaid® tote of medication in to the pharmacy and we go through each one to make sure if she is taking them as prescribed.
I wanted to share a story with you about a very good customer who had a run-in with MEDCO. Mr. “M” just received a 90 day prescription in the mail from Medco for Atorvastatin. It was filled on 1-25-2012 at Medco and shipped to him. He did NOT request this nor did he ever give his permission for Medco to fill this rx. He told me that they call him at least once a month to try to talk him into going mail-order, but he adamantly refuses and tells them to stop calling (which they don’t). This time Medco called his doctor’s office for the refill and told them that Mr. “M” wanted to get it through Medco, so the doctor’s office gave them the prescription. They filled and sent it without Mr. “M’s” permission!!! Now Mr “M” has been coming to my store for over 30 years. He’s a good, loyal customer and is a good person and loyal citizen of this country. He emigrated here years ago from Italy, and yes, speaks with a heavy accent. However, he is very intelligent and knows the English language as well as I do. He is no fool.
When he was showing me the package that he just received from Medco, he was very upset and could not understand how “these insurances are able to do things like this without asking him”.
In addition, I have to add the fact that we just filled his prescription on 1-16-2012. How was Medco able to fill another prescription so soon?!!! Mr. “M” wanted to know this also. He is also concerned that our store would not be able to fill his next refill because Medco already filled it (he’s calling them immediately to give them hell and to tell them that he did NOT order this rx and to take it back).