9/20/2016 by Share Your Story

Pharmacy Benefit Managers: CVS Health, Express Scripts won’t fill your prescription

CVS Health and Express Scripts, two of the country's largest pharmacy benefit managers, have recently dropped coverage of life-saving medications. What will it mean for patients?


Patients Rising responds to CVS Health, Express Scripts cut to vital medications

CVS Health and Express Scripts, two of the country’s largest pharmacy benefit managers, have recently announced plans to drop coverage of dozens of life-saving medications.

The cutbacks are likely to cause major disruptions for millions of patients, who will no longer have access to the right treatment prescribed by their doctor. Here at Patients Rising, we’re shining the spotlight on the cutbacks. Too few patients are aware of CVS Health and Express Scripts’ actions.

Over at The Huffington Post, our co-founder and policy director Jonathan Wilcox educates patients on the implications of CVS Health and Express Scripts‘ plans to drop coverage.

“Basically, regardless of what your doctor determines is best for you, the final decision is in the hands of the of the pharmacy benefit manager and not your medical provider,” Wilcox writes. “If this becomes standard operating procedure, we have likely taken a step from which there is no return.”

He concludes, “Entities like CVS and Express Scripts can play a vital role, but they owe patients more than to silently and anonymously do things once unimaginable, but now outlined in black and white as financial corporate policy.”

The Patient’s Perspective: A Day or Two Behind Can Cause Massive Issues

From the patient’s perspective, the decision by pharmacy benefit managers to drop coverage of a medication can cause major disruptions in ourhealth.

In effect, the judgment of your doctor is swapped in favor of an accountant. Patients are told that the treatment they need — the treatment that is right for them — is not available. For many patients, changing medications can cause weeks or months of side effects. And that’s under the best circumstances– assuming the new treatment works.

In a recent interview with the New York Times, one rheumatoid arthritis patient describes what it means for patients when pharmacy benefit managers drop coverage of treatments.

“Jumping through hoops may not seem like a big thing to somebody that doesn’t have to live with the condition,” Nicole Martin, 33, of Blaine, Ky., who has rheumatoid arthritis and takes Enbrel, told the New York Times. “But even being a day or two behind can cause massive issues for somebody.”

Coverage Cutbacks Mean Big Profits for Pharmacy Benefit Managers

CVS Health and Express Scripts are terminating coverage of vital treatments, while raking in billion-dollar-profits.

Back in August, the same day CVS Health cut coverage, it announced $43.73 billion in revenue for the second quarter — beating earnings expectations while sending their stock price higher. On the company’s earnings conference call, CVS Health CEO Larry J. Merlo credited the company’s pharmacy benefit manager, or PBM with the “gross wins” from its drug rationing efforts.

“I’ll start with the PBM. And I’m pleased to report that with our differentiated value proposition, we see 2017 shaping up to be another successful selling season,” Merlo said on the earnings call. “We currently have gross wins of approximately $7.4 billion and net new business of approximately $4.6 billion. These new business numbers do not include any impact from our individual Med D PDP.”

That’s $1.1 billion in free cash during the quarter, more than $2.9 billion year-to-date, by blocking patients access to the right treatments. “Gross wins,” indeed.

Express Scripts, while not nearly as well-known as CVS, recently announced a growth in second quarter profits by nearly 21 percent with a net income of $720.7 million. The broker also announced its own 2017 formulary exclusion list – 85 drugs in all. What does that mean if you’re one of the many patients who needs one or more of those 85 medicines?

Know Your Jargon: Pharmacy Benefit Managers

Of course, many patients are likely wondering: what exactly is a pharmacy benefit manager?

What They Are: Insurance companies and big companies outsource the administration of drug benefits to PBMs, which frequently save money by limiting patients’ access to life-saving treatments. Think of them as the middleman that does the dirty work encouraging patients to fail first.

Why They’re Bad for Patients: PBMs operate entirely in secret. Even PBM clients can’t access information. Susan Hayes, who works as an auditor of PBM contracts, told USA Today in February, that “auditors aren’t allowed to copy or take pictures of documents when they audit a PBM’s rebate contracts… In recent proposals from Caremark that she reviewed for clients, Caremark provided a flat amount for a rebate and not 100% of rebate savings.”

In the News Today: The U.S. Department of Justice is taking notice of the secrecy and questionable practices surrounding pharmacy benefit managers, and has launched federal investigations of PBM contracts, according to BioPharmaDive.com.


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