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One PBM is taking the “special” out of “specialty care”

PBMs require their patients to adhere to one-stop shopping for specialty medications, per an October 19 article in Modern Healthcare. But not all pharmacies are created equal.

When it comes to specialty conditions such as HIV/AIDS, multiple sclerosis, rheumatoid arthritis, anemia, and even cancer, the “special” label that describes the condition, medication and care isn’t a meaningless label.

These are chronic, complex diagnoses, that have significant impact on quality of life. It generally takes an entire care team of different specialists to properly care for patients with these conditions.

But maybe CVS Health’s Caremark doesn’t see it that way.

According to a recent article in Modern Healthcare, the AIDS Healthcare Foundation has rallied behind a group of patients with HIV and AIDS who are suing CVS Health’s Caremark, alleging that the pharmacy benefit manager (PBM)’s practices violate the law.

Why do we care about PBMs so much? Because the three biggest pharmacy benefit managers are owned by – you guessed it – insurers. Whatever profits PBMs make, you can bet your bottom dollar its to the benefit of the insurance companies that own them. Clearly, we’re passionate about this subject – but when PBMs are the ones handling your medications, the issue matters.

Case in point: CVS Health Caremark requires its members to receive prescriptions from a CVS pharmacy, whether by mail or at a retail store. And if you don’t use their pharmacy, rather than it being a free-market decision, you suffer the consequences: you’re forced to pay out-of-network rates for prescriptions.

Here’s a thought: patients might just prefer to pick up their prescriptions from a location that’s convenient and familiar to them. They might want to support a locally owned pharmacy. It’s crazy to us that the patient is stuck with a bill all because they made an economic decision that’s well within their rights to make.

But beyond that, there’s medical risk on the table, too. Specialty drugs are used to treat complex conditions that often require significant oversight from providers, and forcing patients to pick up their prescriptions at CVS Health Caremark pharmacies can impact the quality of their care.

According to the article, “For people living with HIV/AIDs, real specialty pharmacies and pharmacists that focus on HIV/AIDS and in-person treatment provide demonstrably superior care than do mail-order pharmacies and retail pharmacies,” Jonathan Eisenberg, deputy general counsel for litigation at AHF, said in a news release.

Hear, hear!

Ultimately, PBMs have a lot of market power, which means a lot of control over patients. And CVS Health Caremark – which is owned by Aetna’s parent company, CVS Health –  is the biggest PBM in the country.

Just this year, Texas outlawed PBMs from steering patients to pharmacies they own, calling the practice “anti-competitive” because it limits patient choice.

Good for the Lone Star state, but it looks like patients elsewhere will keep having to sue for the ability to get the care they need – and where they want it.

Doesn’t sound very “special” to us.

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