“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey
passionate pachyderms
Pharmacist Steve steve@steveariens.com 502.938.2414
Some are wondering why their PBM/Insurance is creating “preferred medications” for pts with specific health issues. The only answer is the MIDDLEMEN in the medication distribution system.
“EPIGATE” is a fictional term to describe the rapid price increase on EPIPEN (auto injector) used for asthma attacks and acute/severe allergy reactions ( anaphylactic shock ).
the graphic above explains where the pt’s money goes that they pay at the pharmacy counter. In this example $608.00
Out of that $608 dollars:
the pharmacy gets $30 – gross profit of abt 5%
the wholesaler gets $20 – gross profit of abt 3%
The pharma gets $274 – gross revenue of abt 45%
the Insurance/PBM gets $259 – gross profit of 43%
the broker gets $25 – gross revenue of abt 4%
I am not really sure who the “broker” is but there is a middleman that negotiates rebates/kickbacks/discounts from pharmas for the insurance/PBM companies.
The transaction goes like this… the pharmacy collects $608 from the pt… the pharmacy pays the wholesaler $578 for the Epipen. The wholesaler pays the pharma $558 to the pharma. The pharma pays the broker/insurance/PBM $284
46% of the dollars the pt pays at the pharmacy counter… goes to three middlemen who actually does not even provide a product… just a electronic service of shuffling a claim.
The large percent of the money that the broker/insurance/PBM gets from the money that the pt hands over at the register is largely obtained via coercion.. Those middlemen tell the pharma that if they want their particular medication on their approved formulary the pharma will provide a discount/rebate/kickback (commonly referred to as “the spread”) of a certain percent – often as high as 50% of the wholesale price back to them… OR… in order for the PBM to pay for their product.. it will only be via a PRIOR AUTHORIZATION PROCESS…. which everyone knows that a prescriber will take the less timely route and prescribe the med that is already on their formulary for a particular health issue.
IMO, we are seeing many PBM’s making buprenorphine type products as their preferred med for chronic pain… that is because they can make a lot more money – via the spread – than having a generic opiate being prescribed.
Secondly, there are some rumors that those law firms that are now suing the pharmas , pharmacy wholesalers and chain pharmacy … will at some time in the future turn their focus on the insurance/PBM industry to sue because they have facilitate the opiate crisis by paying for all those opiates that have been prescribed.
It will probably be several years before that happens and the PBM/insurance industry wants to be in the position of defending themselves by point out that they have move more and more chronic pain pts over to buprenorphine products.
When all is said a done… buprenorphine is still a controlled substance (C-III) with a potential for substance abuse/addiction and diversion. There has been a small number of clinics treating SUD and chronic pain pts with this medication that have been raided by the DEA and some pts have been selling their buprenorphine on the street to get money to buy their drug of choice to abuse.
You can put “wings” on a pig… and it still will not be able to fly.
What’s in the news: Walmart Inc., the world’s largest retailer, said it is delaying a previously announced move to mandate electronic prescriptions for controlled substances (EPCS) that was scheduled to begin Jan. 1, 2020. The AMA and other medical societies had been urging the delay.
“The AMA welcomes Walmart’s decision to delay implementation of an electronic prescribing mandate that would have resulted in harm to millions of Americans, including many in rural areas who rely on Walmart as the only pharmacy in reasonable distance,” said AMA President Patrice A. Harris, MD, MA.
“The policy, which the AMA urged Walmart to delay, was not developed in consultation with the nation’s physicians, who support electronic prescribing of controlled substances, but want to see it implemented in a manner that supports—rather than disrupts—patient care.”
Why it matters for patients and physicians:
Only about 44% of physicians have the technology to submit electronic prescriptions for controlled substances (EPCS)
Without a delay in implementation, “patients in every state” would have suffered “negative consequences from not having their necessary medications dispensed,” AMA Executive Vice President and CEO James L. Madara, MD, wrote in a letter to Walmart Chief Medical and Analytics Officer Thomas Van Gilder, MD.
Patients affected by the move, Dr. Madara wrote, would likely have included those “receiving care for opioid-use disorder, anxiety, depression, attention deficit hyperactivity disorder, auto-immune diseases, HIV/AIDS and painful conditions like sickle cell disease.” It also would likely have made it impossible for thousands of Walmart’s own employees to fill their paper prescriptions in a Walmart pharmacy.
Not all EHR vendor products can satisfy the requirements for EPCS, and that implementation has been set back due to questions about certification, patient concerns and cost to prescribers, Dr. Madara noted in a letter earlier this year to vendors asking for their help to change the situation.
The burden does not lie solely on vendors’ shoulders, the AMA says. More should be done to modernize Drug Enforcement Administration (DEA) rules for EPCS to let doctors deploy the user-friendly devices they already have—such as fingerprint readers on laptop computers and mobile phones—to satisfy multifactor-authentication requirements.
What’s next: A federal law enacted in 2018 requires the DEA to modify those requirements, and the agency is working to make the changes. The measure—the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, or SUPPORT Act—requires that, starting Jan. 1, 2021, Schedule II–V drugs prescribed to patients with Medicare Part D prescription-drug coverage be submitted electronically.
The SUPPORT Act allows for multiple exceptions to the ECPS requirements. States have added other exceptions and ways for doctors and other health professionals to apply for a waiver from the ECPS requirements.
Walmart’s move to delay implementation of its electronic prescribing-only applies to the pharmacies in the company’s Walmart and Sam’s Club stores.
One of my readers asked me to write something how the following medication differ:
Buprenorphine/(Subutex): Is administered sublingual (Under the tongue)
Buprenorphine/(Sublocade): administered as a SubQ injection monthly
Buprenorphine/Naloxone (Suboxone): Administered sublingual/buccally film strip
The common ingredient Buprenorphine interacts with three different opiate receptors (Delta, Mu,Kappa) and according to this article … there is NO MME EQUIVALENTS for this medication
The Naloxone/(Narcan) also interacts with various opiate receptors and is suppose to help make Suboxone abuse resistant
Prescribers are required to go thru special training in order to legally prescribe these medications and their DEA license number will be altered to start with a “X” so that pharmacists will know that the prescriber has the legal authority to prescribe these medications.
I checked two difference references and one only lists Buprenorphine is to be used for addiction and the second had a small mention of it being used for mod-severe pain.
I have read reports of the DEA starting to raid practitioner’s offices that are prescribing one or more of these products and there has also been reports of people selling these on the street so that they can get money to buy the drug of choice to abuse.
I have read reports from chronic pain pts across the spectrum of working well, to working for a short period of time, to working very poorly or not at all
My major concern of chronic pain pts using this medication for pain management is that when they change doctors or get admitted to a hospital or go to ER… that regardless of what diagnostic codes are on the pt’s records. The practitioner will jump to the conclusion that the pt is being treated for has been treated for substance abuse and even worse add the ICD10 code to the pt’s electronic medical records that they are a substance abuser.
Many hospitals systems, that own numerous office practices have a electronic medical record system that works off of central server and what is put on the pt’s electronic medical record by one staff practitioner will show up not only on that particular hospital system but also showing up on all other hospital systems that use the same system.
Looking at the Electronic Medical Records that our local hospital system uses… it shows a list of OVER 100 other hospital systems that use the same system and a pt changes doctors, moves their electronic medical records can be quickly retrieved … including all ICD10 diagnostic codes anyone the pt has seen has added to their medical history.
A pt that has had a SUD (Substance Use Disorder ) incorrectly added to their medical records may be damn near impossible to get it off their medical records.
Likewise taking one of these medications and the pt is in a accident or in need of surgery – especially emergency surgery – may not be able to get adequate anesthesia or pain management because this medication(s) has all the opiate receptors all “tied up” because it has a mean half-life of 31-35 hrs and they claim that for the body to totally eliminate a medication that it can take up to SIX HALF LIVES… With this medication that could be up to 9 days.
Pharmacists receive extra training to prevent excess opioid prescriptions
MEMPHIS, Tenn. (WMC) – A Memphis pharmacy company is making sure pharmacists are trained to fight the opioid epidemic by rolling out a new continuing education plan to stop addiction and spare lives.
In 2018, during then-Tennessee Governor Bill Haslam’s administration Tennessee overhauled its prescribing laws to fight the opioid epidemic by putting prescribing limits in place. And while statistics are showing positive signs, medical professionals said there’s more work to be done.
“Almost all the states we work in have some sort of opioid issue going on,” said Rod Recor, Chief Marketing Officer of Comprehensive Pharmacy Services.
The Memphis company has operations in 47 states with 1,600 pharmacists running pharmacies in health care facilities.
“More and more pharmacists are becoming part of care teams. In many of our hospital clients, we have care team approaches to delivering care,” he said.
The company just announced a new stewardship program, a 20-hour training module with video lectures, written activities, and a practicum. The program is aimed at training pharmacists to limit opioid use and find other ways to treat chronic pain. Recor said the company just started their first class of participants.
“This stewardship program really goes to supporting those rules and legislation in Tennessee and other states as well,” he said.
Tennessee tightened opioid prescribing rules in 2018 under a plan known as TN Together. Doctors can write a 3-day opioid prescription with no requirements before prescribing. But doctors may only issue a 10 or 20 day prescription after checking a state controlled substance monitoring database (CSMD), explaining why an opioid was issued, and including a specific diagnosis. Doctors may only prescribe 30-day dosages for “medical necessity.”
The Tennessee Medical Association (TMA) reports opioid prescriptions in the state have continued to decrease and inquiries to the CSMD have increased dramatically, a positive sign, showing more medical professionals are logging in and engaging in prevention.
Despite that, statewide drug overdose deaths attributed to opioids are still trending up, sitting at 1,304 in 2018, the highest in a 5-year time span.
Shelby County reported 123 opioid overdose deaths in 2018, according to TN Department of Health data. That number is down from 159 in the year 2017.
An update has been made to the PPM Opioid Calculator to remove conversions to and from buprenorphine. Here’s why.
While the original launch of the free PPM online opioid calculator in 2012 did not include any conversions to or from buprenorphine due to its complex pharmacology and pharmacokinetics (see below), these conversions were eventually added as several clinicians requested access to the calculation data in order to transition patients to a safer opioid alternative.
Unlike full agonist opioids, buprenorphine has a ceiling, or plateaued, effect on CO2 accumulation. It is important to note that the addition of buprenorphine, including transdermal patches and buccal films, to this calculator came with a preprogrammed conversion ceiling and a warning that conversions to or from buprenorphine could not be recommended. For example, if a user asked to convert morphine 80 mg orally to buprenorphine film (Belbuca), they would receive a warning “Result exceeds maximum daily dose. Patients on morphine 80 mg PO (or equivalent) or higher, must not receive Buprenorphine (BF) due to possible opioid withdrawal risk.”
Fast-forward to the contemporary opioid environment of 2018-2019, where ubiquitous state and federal policies and guidelines continue to push for safer alternatives. In addition to the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, which cautions clinicians about morphine equivalent doses (MEDs), a new 2019 CMS rule will implement soft and hard edits at 90 MEDs and 200 MEDs, respectively.
Neither the CDC nor Medicare cites buprenorphine as having an MED.
Therefore, buprenorphine has been removed from the online calculator due to the following factors:
Buprenorphine is now more commonly considered a safer opioid alternative with efficacy often comparable to or superior to its full agonist cousins (its diminished risk for respiratory depression may also provide safety advantages compared to full agonists)
Prescribing clinicians are often evaluated or tracked based on their MED prescribing habits
Current clinical guidelines seem to align with the position that buprenorphine should not be assigned any MED.
With this change, it is hoped that clinicians may recognize the unique attributes of buprenorphine and see it as a valuable option that does not have a calculable MED by acceptable guidelines.
The complexities of buprenorphine
From a practical perspective, buprenorphine cannot have a linear conversion to/from morphine (or an equivalent) because of its complex pharmacology and pharmacokinetics, including:
Buprenorphine has a higher binding affinity to mu-receptors compared to every full-agonist opioid prescribed for in-home use as well as naloxone (Narcan)
The buprenorphine parent molecule is considered a partial mu-agonist, but will nevertheless overcome receptor binding by concomitant full agonist use
Because of #2, at 80 to 90 mg of morphine equivalent dose (MED), patients may experience withdrawal as the full agonists are displaced by buprenorphine mu-receptor occupation.
This is a pretty long dissertation of this study, appears to be done in/around Seattle WASH in the early 2000’s. So I am not going to post the entire text of the study buy the above link will take you to the entire posting
CVS Caremark, the in-house pharmacy benefit manager for CVS, has been accused of squeezing small pharmacies, driving some out of business.
Lawmakers in Arkansas and Ohio have been quick to pass laws designed to end this by demanding higher transparency or regulatory oversight.
CVS is also trying to buy up small pharmacies, which is much easier to do if they’re going out of business.
The short version of what happened to CVS in 2018 is this: The company got too greedy, and then it got caught.
In its greed, the company squeezed independent mom-and-pop pharmacies. The squeezing wasn’t being done by the part of CVS you buy dental floss from or visit to pick up a prescription, though it’s not unrelated. It’s a behind-the-scenes business known as a pharmacy benefit manager, which manages payments between insurers and pharmacies and drug companies.
The mom-and-pop pharmacies say CVS’ in-house pharmacy benefit manager, CVS Caremark, slashed reimbursements for medications sold to their patients on Medicaid. At the same time, they say, it was reimbursing CVS pharmacies at much better rates. With some of them on the verge of going out of business, these pharmacies have rallied lawmakers — both Democrats and Republicans — to put an end to this.
So now CVS faces a tide of resistance to the way it deals with smaller rivals. Already, Arkansas legislators have passed a law aimed at curbing this behavior. This is new regulation in a Republican-dominated state. That’s how bad things looked to the lawmakers.
Ohio is forcing PBMs to disclose more about the way their pricing and contracts work. Mom-and-pop pharmacists in states like Texas and Kentucky are realizing they have a CVS problem on their hands too. Caremark manages payment for Medicaid-managed care plans in more than 20 states.
This is important because CVS is trying to cut a $68 billion deal to buy a health insurer, Aetna — a deal that would make it even more powerful and more able to obscure the whys and hows of pricing all through the healthcare system.
What’s more, CVS isn’t the only healthcare company trying to turn into a leviathan. Over the past few years the largest healthcare companies — including insurers, PBMs, hospitals, and drug companies — have been combining in what is known as vertical integration, or mergers between companies in the same industry whose businesses don’t directly compete.
They say this is an effort to create efficiency in the healthcare system. What CVS has shown, though, is that this kind of integration can actually get companies drunk on pricing power, and create monopolistic monsters.
In Arkansas
To their credit, once legislators in Arkansas figured out what was happening to local pharmacies, they moved at blinding speed.
The state legislature nearly unanimously passed a bill designed to curb this behavior from PBMs on March 14.
The situation had gotten desperate, fast. The way mom-and-pop pharmacists tell it, CVS started bringing the pain at the beginning of 2018. Suddenly, reimbursement rates for Medicaid plummeted at the same time drug prices for Medicaid started rising. So in the beginning of February, Arkansas Attorney General Leslie Rutledge started investigating the matter.
“The amount paid to the pharmacy was less than half of what was being charged to the plans,” Scott Pace, of the Arkansas Pharmacists Association, told Business Insider.
Pharmacists in Arkansas, for example, say:
For a Fentanyl Patch 100, CVS pharmacies were reimbursed $400.65 while mom-and-pop pharmacies were reimbursed $75.74.
For Amoxicillin, CVS pharmacies were reimbursed $35.92 while mom-and-pop pharmacies were reimbursed $12.21.
For even something as simple as Ibuprofen, CVS pharmacies were reimbursed $5.86 while mom-and-pop pharmacies were reimbursed $1.39.
Sometimes, the pharmacists say, they weren’t reimbursed enough to cover the cost of filling the prescription. These aren’t the only ones, to be clear. Business Insider has seen a long list of alleged disparities like the ones above.
CVS, for its part, denies that it is squeezing the mom and pops. Business Insider sent the above examples to the company, and its spokeswoman Christine Cramer said they were patently wrong. However, she also said the pharmacists were “cherry-picking” reimbursements that look especially bad.
“The facts are that on an aggregate basis, we reimburse independent pharmacies at a higher rate than larger regional and national chains,” she said.
“CVS Caremark considers local, independently owned pharmacies to be important partners in creating our pharmacy networks, and in fact, independent pharmacies account for nearly 40% of our network,” she added. “Furthermore, we reimburse our participating network pharmacies, including the many independent pharmacies that are valued participants in our network, at competitive rates that balance the need to fairly compensate pharmacies while providing a cost-effective benefit for our clients.”
This response did not jibe with what legislators, patients, and pharmacists were seeing on the ground, though.
Out of a $50 drug, for example, say $22 was paid to the mom and pop, the rest went to CVS — to its PBM. At the same time, patients looking at how much a drug cost their health plan in their explanation-of-benefits portal would show a price of, say, $100.
“The numbers were stark,” Pace said.
Here’s the letter pharmacists are getting, urging them to sell their businesses to CVS.Business Insider
So until this was all figured out, people who bought medicines at their local pharmacies in Arkansas (and Ohio) didn’t know that their neighbors were getting screwed. They also didn’t know that, as their local pharmacists were getting squeezed, CVS was waiting in the wings, sending out letters offering to buy the very mom-and-pop shops it was forcing out of business.One pharmacist, Rick Pennington of Lonoke, Arkansas, said that if it weren’t for his business mailing a generic erectile-dysfunction pill to nine states, he’d be out of business.
“When you look at who’s controlling the money and who has the leverage, it’s the PBMs who have control,” Pace told Business Insider. “These folks are trying to get more integrated into the healthcare system, and so far we’ve seen that means patients lose. Next, they’ll buy a hospital and be an HMO. I think that’s bad for patient choice.”
He added: “It’s not a free market because there is no transparency on pricing.”
CVS, however, denies coordination between its PBM and its pharmacies.
“Our retail business has engaged in acquisition activity and outreach to other pharmacies since well before CVS and Caremark merged, and, in fact, the communications materials related to this activity has been relatively unchanged over the years,” Cramer said. “Any retail acquisition activity is completely unrelated to, separated from, and not coordinated in any way with the PBM business’ management of its pharmacy network.”
In Ohio
The story for pharmacists in Ohio is a bit different. There, some have viewed CVS as problematic for years, but instead of seeing reimbursement rates plunge, legislators and pharmacists said they’ve been moving up and down like crazy since around 2015. By October or November of last year, gross annual margins for Medicaid payments to mom and pops were going below zero, and pharmacists were losing money on most drugs sold.
“Because those rates are set arbitrarily you’re set up for a roller-coaster ride,” Antonio Ciaccia of the Ohio Pharmacists Association said in a phone interview with Business Insider. “No one expects to get rich off Medicaid … but if you sat down with a pharmacist that was willing to tell you, ‘Here’s what I was getting paid,’ you could match it up with state-utilization data and see the spread and how significant the loss was … That’s what kind of lit everything up in Ohio.”
And of course, CVS sent those letters soliciting acquisitions. One came on November 9 of last year, a particularly bad time for the state’s mom-and-pop pharmacists.
Suddenly, the number of people in Ohio government demanding answers, led by Ohio Speaker Cliff Rosenberger, started to multiply. They realized that the Ohio Department of Medicaid wasn’t even asking for the right pricing data, and CVS had never considered giving it to them. Now, as rules change within the department, it’ll have to.
Brad Miller, Rosenberger’s press secretary, said this was something his boss had been looking into for years.
“In order to be responsible stewards of taxpayer dollars, you must have access to reliable and accurate data,” he said. “Around the state, we are seeing the negative impact the current system is having on local, independent pharmacies, many of which have been forced to close in recent years. This, in turn, reduces patients’ treatment options and access to care. Having access to this data will go a long way toward lowering prescription-drug costs for patients and employers, as well as help reduce the burden on Ohio taxpayers.”
Ciaccia told Business Insider that during the three years CVS has been engaging in this behavior it has gained 68 pharmacies in the state. Its competitor Walgreens added only two locations over the same period.
“We are done messing around in Ohio,” he said. “This system is completely broken … It is layered and layered with conflicts of interest. I don’t care who the PBM is.”
What a tailor can do!
Health Strategies Group
PBMs have all sorts of tricks up their sleeves to make money not just from pharmacists but also from insurers and drug companies — basically anyone involved in getting medicine to you.Here are a few of their greatest hits:
They can make money (as we’ve seen here) off the spread between what they pay pharmacists and what they charge your insurance plan.
They have gag orders on pharmacists, so your pharmacist can’t tell you whether it’s actually cheaper for you to use plain old cash to buy a drug that isn’t part of your healthcare plan. (Note, the fact that there might even be a cheaper alternative challenges the PBMs’ claim that they save money for their clients in the first place.)
They get reimbursements from pharmaceutical companies. The fatter the rebate, the more likely they’ll include a company’s drug in a client’s (your) managed-care plan, but they don’t have to share that reimbursement with the client (you). They can keep some and negotiate rebates for themselves. They can collect all kinds of administrative fees and other types of fees from drug companies too.
We’ve been learning about this slowly. Three PBMs — CVS Caremark, Express Scripts, and UnitedHealth Group — control about 70% of the US market, and they guard their secrets zealously. Recently, though, the news site Axios published a contract template for Express Scripts. No two contracts are alike, and Express Scripts grumbled that the one Axios published (which was rife with loopholes to make Express Scripts money at every turn) was old and irrelevant.
Yet the company demanded that DocumentCloud, where the contract was posted, immediately take it down, citing copyright infringement.
This “Oh it doesn’t matter to our business — but DON’T TOUCH THAT!” response is trending in PBM world.
For example, earlier this month the US Senate introduced the Patient Right to Know Drug Prices Act, which would ban the so-called gag clauses mentioned above (as Arkansas lawmakers did in their bill).
The Pharmaceutical Care Management Association, the PBM lobby, responded to that by saying:
“We support the patient always paying the lowest cost at the pharmacy counter, whether it’s the cash price or the copay. This is standard industry practice in both Medicaid and the commercial sector. We would oppose contracting that prohibits drugstores from sharing with patients the cash price they charge for each drug. These rates are set entirely at the discretion of each pharmacy and can vary significantly from drugstore to drugstore.”
Sounds as if they’re for it, right? Wrong. Here’s the next sentence.
“Fortunately, to the degree this issue was ever rooted in more than anecdotal information, it has been addressed in the marketplace.”
Rep. Earl “Buddy” Carter of Georgia.C-Span, screenshot
So which is it, guys? Do you think transparency is important and support patient rights — or are you going to fight this bill?It’s a simple question. And it’s easy to see the answer.
Rep. Buddy Carter, a Georgia Republican, introduced the Prescription Transparency Act to the US House of Representatives this month. It does basically the same thing as the Senate bill, and, as the only pharmacist in Congress, he knows he’s facing a street fight from the PBM lobby.
“They spent $600,000 against me when I first ran for office three years ago to try to get me defeated, and over the past few years we’ve seen them ramp up their political activity,” Carter told Business Insider. He’s also noticed that legislators in Washington are finally waking up to the urgency of this situation. There have been hearings about drug pricing in both houses, and Scott Gottlieb, the commissioner of the Food and Drug Administration, has come out swinging especially hard, saying that the PBMs sit at the top of a “rigged system.”
“We’ve seen some companies that dropped the PBMs such as Caterpillar and they’ve been able to control drug prices,” Carter said in a phone interview. “Right now the focus is on prescription drug pricing, and the most impact we can have on pricing is to have control on transparency from the PBMs.”
If you believe that, you should also believe taking that control won’t be easy. Once we do, though, it may change the way you look at what our healthcare is trying to become.
Sadly, this is one of several transplant patients that I have heard of whose life will be at risk over this weekend because their transplant medications will not arrive on time. It’s not against the law for #PBMs to risk lives as they force to their mail-order pharmacy. That’s how they make profits. Sadly, these medications are most likely available at a local pharmacy, but the PBMs want to hoard the business for themselves. PBMs and their mail-order pharmacies will classify a drug a specialty drug, so they can force or steer us to their mail-order pharmacy by making patients pay 100% of the cost if they use their TRUSTED local pharmacy. #stopPBMabuse
How do insurance companies decide what medicines to pay for and when to pay for them?
Insurers and other payers look first at how well the drug works – not its cost – when they decide whether to cover the latest treatments, according to the nation‘s largest pharmacy benefits manager, Express Scripts.
The price patients eventually pay gets determined later, when an insurance company or pharmacy benefits manager decides where a drug fits on a list of covered treatments called a formulary.
The cost of prescription drugs has become a growing source of concern with doctors and patients, but it‘s not a factor considered by an independent committee used by Express Script to determine coverage of a new drug, Chief Medical Officer Dr. Steve Miller said.
That committee – 15 doctors and a pharmacist – reviews the information that federal regulators used to approve a drug and then decides whether it should be covered.
Some payer coverage decisions come with qualifications like a requirement that patients meet specific criteria or try other treatments first. That can limit patient access. Doctors say some patients have had trouble getting a new cholesterol-lowering drug, Repatha, that costs $14,000 a year, because of the restrictions.
Insurers largely use pharmacy benefits managers to set up the lists that determine how much a patient ends up paying. Some lists are divided into tiers, with drugs on the bottom generally being generic or least expensive. Those on the highest tier might include specialty medicines that could cost the patient hundreds of dollars even with coverage.
Whether a drug even gets on the list can depend on whether a similar medicine is already in the market and that can be found with options as a Canadian Pharmacy that offer medicines online. When the ground-breaking hepatitis C treatments Sovaldi and Harvoni from Gilead Sciences debuted a few years ago, Express Scripts had to include them. They cost more than $80,000 for a course of treatment, but the drugs essentially cure a debilitating disease and they had no competition.
But once the drugmaker AbbVie produced a third option, Viekira Pak, with a similar cure rate, Express Scripts was able to negotiate a price discount and switched to covering only Viekira Pak.
The nation‘s two largest pharmacy benefits managers, Express Scripts and CVS Health Corp., both say they cover Repatha.
Sorry we are not currently accepting comments on this article.
Editor’s Note: Terri Lewis, Ph.D. is a chronic pain advocate who, with the help of you, the readers of the National Pain Report, conducted one of the largest online surveys of chronic pain patients.
She sent us this report recently that speaks to the taper issue. It is a long read but we are going to publish much of it because she shared so many of the comments that survey respondents left.
Here was what she shared:
In a national survey of patient 4619 self-reports regarding interactions with pain management, 77.38% of respondents are female, and 21.35% are male. The bulk of respondents range in age from 40 – 70+ and the majority have at least some college or trade school education to report. Many hold post graduate professional degrees. The vast majority meet the definition of multiple chronic comorbidity or MCC – that is they have more than one progressive condition that requires treatment and that affects multiple body systems.
Responses from female respondents regarding their current experience with opioid prescribing as follows:
Abandonment – loss of a physician to provide appropriate medication management
Step therapy- replacement of existing routine with alternatives that may or may not provide an appropriate or satisfactory alternative to existing care routine
Involuntary taper-Rapid reduction or removal of opioids without patient choice making involved and as a contingency for continued care.
In many of these reports, patients provide ample evidence that opioids have been replaced by other drugs of concern, including anti-epileptics and anti-psychotics, or they have been forced to agree to invasive interventional procedures or unnecessary surgeries in order to continue under some kind of a care umbrella. Many report their physicians cite CDC regulations as law or DEA scrutiny as their reason for insisting on taper. Protesting the appropriateness of these alternatives seems to fall on deaf ears or result in discharge in many cases. Many feel strongly that physicians are dismissive of their concerns because of their gender. Thirty percent (30%) are enrolled in Advantage Plans. Respondents submitted reports from every state in the nation and two territories.
Within these responses are reports of suicide and plans for suicide when alternatives for care and relief are exhausted.
I have printed off some of the unedited commentary from female respondents, which align with the findings in Fenton JJ, Agnoli AL, Xing G, et al. Trends and Rapidity of Dose Tapering Among Patients Prescribed Long-term Opioid Therapy, 2008-2017. JAMA Netw Open. 2019;2(11):e1916271. doi:https://doi.org/10.1001/jamanetworkopen.2019.16271.
I am still deep into analytics. So this is not the final analysis, but it’s a credible snapshot.
Here are some of the comments left by those who took the survey.
I am currently as of February 2018 being FORCE TAPERED due to this hysteria My PM dr. Is force tapering me due to CDC Guidelines even though she said I was doing well on my high dose meds. She is afraid to lose her license.
Morphine forced tapered from 90mg to 15mg & dilaudid forced tapered from 4mg to 2mg.
Kaiser Permanente of Colorado says the 2016 CDC prescribing guidelines are actually law (even though I know the are not) so I was forced to taper from 135mme to 120mme last summer. Now that it is 2019 I must accelerate my taper to comply with the 90mme “law” from the CDC.
Terri A Lewis, PHD
I have a spinal stimulator that was placed to facilitate the original, willing, taper, and I have had to significantly increase the level of stimulation due to the loss of effective pain management. My doctor has replaced my gabapentin with Lyrica in an attempt to find better pain control as she refuses to return my pain medication to the level it was prior to the forcible taper by my previous doctor. She has referred me to a neurosurgeon to evaluate my back and to a physical therapist, at my request. The previous doctor claimed the reduction of my pain medication was due to FDA guidelines, despite the fact that I was already at a level of 90 mg morphine equivalent per the CDC’s recommended guideline of Oxycodone.
When I lost my pain doctor for that brief period, I was forced to take the following medications even though I had already tried them in the past (tried them one at a time): Lyrica – caused severe dizziness. Cymbalta – cause my liver enzymes to elevate, just like in the past. Flexeril instead of Soma – did nothing for my muscle spasms. Can’t remember the other medications but there was another one. My pain meds were cut by approx. 65% and my muscle relaxer was taken away. I was told that I had a choice of either getting a pain pump or a spinal cord stimulator or they would no longer prescribe my pain meds (had 2 SCS’s in the past). I was also required to redo all imaging, PT, drug screen every 2 weeks – otherwise, no pain meds and “if you don’t like it – go somewhere else”. I was supposed to go to biofeedback and other alternative treatments, and start ESI injections in order to continue getting my pain meds but I found my old pain doctor before I had to do any of the other treatments. I have had sympathetic blocks in the past with relief for only 24-48 hrs, and ESI won’t help my RSDS! I did have a spinal cord stimulator implanted (it was my 3rd one), by my old doctor, but that was just done recently and it was because he had to taper my meds, so I needed something because I was already having a lot of breakthrough pain even before he tapered me, but I was trying to tolerate it and work part-time. So I really had no choice. I’m in a w/c due to a complication with my first SCS and another “alternative treatment” 19 yrs ago. The doctor who put my most recent SCS in (my doctor’s partner), put the battery in the wrong place (instead of in a fat pocket in my hip or abdomen, he put it right over my largest back muscle next to my spine – low back, NOT hip where the fat is). So now I need another surgery to move it! It’s causing much more frequent and severe muscle spasms. My current doctor who I have been with for approx. 18 years with the exception of about 3 months, also required that I try various other medications but I expected that. Opioids was certainly not my first choice but it is what works!
Hawaii has no opioid limits but my pain management doctor is force tapering me saying “it’s coming ” and “your insurance will stop paying for it so you better get used to it “. He didn’t force taper me the month I agreed to bilateral epidural injections.
Methadone was initially prescribed as pain reliever, not as a bridge from one drug to another. I have decided to try and taper off methadone and try to use a less potent medication to fit in CDC recommendations of 90MME Max for my pain control. When I made this change or decision I was denied any help in the taper . Currently my regular doctor is trying to help but this may not last.
BotoxInvoluntary taper Reduced dose Dr #2 added botox injections which one time was HIGHLY effective but he has been unable to duplicate the exact injection site ever since. Also, he reduced my narcotics on day 1, no tapering ! He reduced oxycodone as follows old dosage 6 30mg/day=180mme and new dosage 4 10mg/day=40mme. Morphine old dosage 2 40mg/day=80mme new dosage 2 30mg/day=60mme. Bottom line? My old dosages totaled 260mg/day. My new dosages totaled 100mg/day. On less than half of my former dose, where I was stable and functioning, I am now reduced to living in pain that’s grown exponentially and reduced my functioning status to living on my heating pad in bed. Every. Single. Day.
Epidural injections (ESI)Involuntary taperSpinal cord stimulator When I was seeing a previous pain mngt dr, I was told I HAD to get the steroid spinal injections (which I later found that with my disease, the steroid injections only eat away at the collagen that my body is already low in since EDS is a collagen disorder). I was so desperate for help that I requested the spinal cord stimulator to help with low back pain but once I got it, it helped the CRPS in my feet some, the extreme pain in my knees some, but helped my lower back not at all. Very disappointing. Once he found that I was not getting relief from the spinal cord stimulator for my lower back he decided it was “time to taper back” on the oxycodone he was giving me, like my illness was suddenly improving, while I was only getting worse. It was horrible.
Involuntary taperOpioidsPain medications I have been forcibly tapered by SIGNIFICANT AMOUNTS from my successful dose of opioid pain medication against my will, leaving me in excruciating pain and virtually bedridden and homebound.
Anti-depressantsInvoluntary taperNeuroleptics (Gaba, etc)Opioids Yoga or Tai Chi When I was first told they’d be force tapering me they offered me antidepressants even though I am not depressed and recommended Tai Chi. These were the only alternatives offered as we had already tried Gabapentin, Savella, Amytriptaline, Lyrics, Abilify, Topomax, and a few others I’ve forgotten. I had severe reactions to several of them and no pain relief. I was encouraged to seek other physicians, though can’t find any willing to take a patient on opioids and some just won’t take Fibromyalgia patients.
ChiropracticInvoluntary taperPhysical therapy Step therapy New Physician is requiring me to taper opiates and eventually stop them as she doesn’t believe in using them. Wants me to see a chiropractor Am already getting Physical therapy, and using relaxation techniques.
BotoxInvoluntary taperMedical CannabisOpioidsPain medicationsSurgeryTENS Unit Before I was tapered I went to PT, warm water exercise, used tens, medical marijuana. I still use all of that. I failed methadone, neurontin, Botox, Marcane injections. Too painful and developed antibodies to Botox. My low platelets prevent spinal injections as well as surgery. Neurontin caused suicidal thoughts, psychotropics caused exacerbation of dystonia and tardive dyskinesia caused by misover prescribing of Reglan. Damage permanent. Only drugs that don’t exacerbate movement disorder and bleeding disorder are opioids
Involuntary taperOpioids I have been forced to taper by other physicians in the office even though they know my diagnoses because they don’t like opioids.
Again, with my move a year ago to a new state, it has been extremely difficult getting established with new doctors. And in most instances, near impossible. No one here wants to take on complicated cases, especially when it involves chronic pain. Several of my medications are being forceably tapered , and I am experiencing drastic loss of quality of life. No other alternatives for opiates exist for me. Yet I am being asked over and over again, to retry drugs such as Gabapentin, Lyrica, Topomax, etc that in the past have resulted in intolerable side effects, even hospitalization! Why would I want to retry a drug that I was not able to tolerate previously? Why are injections still being brought up to me, when I should NEVER have them again?
Before guidelines I was forced to taper and it cause major health issues so then doctor increased. Also after level 3neck fusion surgery Surgeon refused to treat severe pain that had kept me awake for 7 days I slept a total of 2 hours in 7 days family doctor seen I was in dire straights and gave me a fentanyl patch so I could recover he was gone on vacation after my surgery.everyday I begged Surgeons MA and RNs to give me stronger pain meds I was told to meditate,Pray listen to music I was ready to check out of life . ER refused to even see me .because the surgeon . so then went to family doctor office my doctor was on vacation and not in and then seen an RN and she would not even let me see a doctor that was my an associate of my family doctor as he was on vacation. Because of the severe pain RN’s were acting as doctors when my family doctor got back from vacation I had to lie to get into see my doctor .
Was told they would put me on suboxone for pain I was tapered for 9 months due to state laws, but I went to capital and fought for exemption trigger point injections were pushed on me even though I am allergic to steroids and I told him I did not want any more invasive treatments Living Life Well class was mandatory. He still makes me go to alumni meetings on Monday nights. I’d rather have a root canal
60 my of morphine sulfate per day and 2, 10 mg oxycodone per day. Every month they are tapering me down!!
I don’t understand above questions. Yes my Norco was tapered from 70 mg to 50 mg a day due to DEA recommendations. I use stimulation, epidurals, OTC Advil, lidocaine patch and compounded AIF cream for pain. Since lowering my norco mybpain is now unmanageable and nerve pain is miserable. All I want is relief to a level that is tolerable. I will never be pain free but a level of 5-6 is what I need and 60-70 mg a day of opiate worked fine for me. Now I’m couch ridden.
I had been using Fentanyl Transdermal patches, last month dosage was reduced—pain increased, oxycodone-same, Flexeril-stopped totally, Xanax—stopped totally-NO TAPER OFF, Duloxetine-same. Last month Dr. required me to fill prescription for NARCAN!!!! He said it was required— in case I overdosed!!!!! I am 69 years old!! He has known me to be a very compliant patient for 20 years!!!!! Now I had to spend $24.10 for something that I will have in my safe??? I don’t plan to O.D.—- but, if I did, who would deliver it to me??? We are pain patients, not Illicit drug addicts!!!
I have had a forced taper of the Morphine which has caused me to be put on Topamax (my version of Gabapentin/lyrica) to help with nerve pain, recieve various steroid injections, radio frequency ablation and I am now in the process of getting the spinal simulator implant to hopefully provide more relief. I currently can do very minimal activity & have little to no quality of life due to my pain levels.
No change in prescriber or physician, but i am now on a forced taper to comply with state rules.I take other medications in conjunction with opioid therapy but they only compliment it. Without opioids, they fail to reduce pain in any noticeable measure.
Some are wondering why their PBM/Insurance is creating “preferred medications” for pts with specific health issues. The only answer is the MIDDLEMEN in the medication distribution system.
