On Tuesday, President Trump signed what is, to me anyway, one of the most meaningful executive orders of his presidency to date. The president signed an order aimed at pharmacy benefit managers, which I have previously written about here.
The executive order will allow for standardizing Medicare payments for prescription drugs wherever the patient gets care, pretty much eliminating “specialty pharmacies.” There is nothing special about these pharmacies, but they allow for a monopoly of drugs to be provided only by pharmacy benefit manager-owned pharmacies.
These “specialty pharmacies” gain exclusive access and charge a significant amount for medications that would otherwise be cheaper at their local independent pharmacy. I have patients who have PPO/HMO insurances and require drugs such as Tacrolimus, Sirolimus, or even Mycophenolate. These are generic drugs and have been for years. My reimbursement is usually 30-50$ for tacrolimus, 1-200$ for Sirolimus, and 40-75$ for mycophenolate. It all depends on the number of pills and the plan.
Meanwhile, at the specialty pharmacy, patients will pay much higher copays, and the PBM will reimburse its own pharmacy 2- 3 times the amount as compared to any other non-affiliated pharmacy. As you can see, when the time comes to discharge a patient after having a bone marrow transplant (to treat their leukemia), the discharge is held up by requiring a “specialty pharmacy” to provide just those medications. While PPO/HMO plans require this to be sent to their PBM-owned pharmacy, Medicare/Medicaid reimburse all pharmacies.
I have a family member who has ulcerative colitis; it runs genetically on my mom’s side of the family. Most oral medications are covered by insurance, but if there is a “specialty drug” required, it has to be administered through our insurance PBM-owned pharmacy. You are at the mercy of the high copay, whether the medication works or not. By eliminating this practice, it is estimated to lower prices of prescriptions by as much as 60 percent. This family member just tried Tremfya, a drug that costs about $14,000 wholesale. Per the itemized bill, the drug was billed for $122,000, with a co-pay of $8790.00. By the way, she failed this medication and is stuck with the bill. That was all for one infusion — from a specialty pharmacy.