You never know what brings people to try a compounding pharmacy, but it usually involves their quest for truth. One of our patients, Eva, is a case in point. Her story will probably feel familiar to you because in a way, we all live this. You see, what your insurance company doesn’t want you to know cost Eva, and will cost you too.
It has a lot to do with the rising cost of medication and compounding pharmacies’ benefits to patients, especially in today’s political climate. So we thought it was worth a share.
How You Pay for Medication Can Shortchange You
Like many other middle-aged women dealing with a thyroid condition, Eva headed to her endocrinologist’s office for her bi-annual checkup. She had been feeling not quite herself the last few months and just chalked it up to being part of the aging process. As requested by her physician, she had gone to their lab beforehand so her bloodwork results could be reviewed during her examination.
Eva works as an independent contractor for a few companies so she is not provided health insurance coverage by an employer. With the recent rise in insurance premiums and lackluster coverage available to her, she had to take her chances on staying healthy and paying cash for her medical services as catastrophic insurance wasn’t even an option, financially speaking.
This was to be her first doctor’s appointment without insurance and she was nervous about having to deal with anything less than a favorable outcome.
This doctor had mentioned something to her six months earlier about how she might want to consider using a brand name prescription or getting her medication filled at a compounding pharmacy. She ignored the idea, knowing that it would increase her out-of-pocket expenses.
In hindsight, she would now recall that conversation similar to the phrase, “You get what you pay for.”
After a disconcerting “Hhhmmm….” Eva’s doctor looked up from the chart in her file and quizzically asked, “So how are you feeling?”
But before she could answer, he half-jokingly added, “I don’t know how you’re even functioning.”
Startled yet amused at the response, Eva said, “Well I am kind of tired. Okay, I’m exhausted. I can barely get through the day and I’m too tired to hit the gym after work and it’s all I can do to stay up until eight o’clock.”
So after learning that her thyroid levels had dropped to dangerously low levels, they began to discuss her options.
Why Potency Matters
For the prior 18 months, Eva’s thyroid levels had been much like a yo-yo, swinging a pendulum of imbalance. She had been on one dose for quite some time but complained of heart palpitations and an increasing inability to sleep.
This is when her doctor lowered her dosage, which led to the issues mentioned during the most recent checkup. But this wasn’t her doctor’s fault. The prescription itself was the cause for concern.
Eva learned that the low-cost generic prescriptions most allowable through insurance companies can skimp or be inconsistent in formulation. Even though her prescription said .80 mg, she was more than likely receiving .60 mg, putting her health at risk. For the unsuspecting and unknowing, this too could put the doctor’s reputation into question.
So why is there such a discrepancy?
A Trip to the Doctor Feels Different Than It Used to, and That’s Good
Most people would never know what was going on until they had to pay cash for a doctor’s appointment, visit to the lab or prescription.
Eva was lucky. She is under the supervision of a specialist who practices bedside manner every day. He truly cares about how his patients feel.
Not only did he explain to her what was most likely going on with her prescriptions, he informed her of the financial connection. If she paid cash for a brand name prescription, it would cost her less out of pocket than her copay would for the generic version, and the potency would be accurate.
Shocking, but there’s more.
Clawbacking Prescriptions Compromise Quality
Health insurance companies and big pharmacies use the services of Prescription Benefits Managers “PBMs” to help facilitate the process between patient and medication fulfillment.
Unfortunately, PBMs dictate what is covered and the dollar amount that is covered for prescriptions. The pharmacist bears the cost for a prescription by the pharmaceutical company.
The insurance company will then dictate the overall cost to the patient and what is the allowable amount to be paid through copayments and the pharmacy.
But what happens when there is an overage and money is left on the table?
Instead of passing on cost savings to the pharmacist and/or the patient, these monies go to the PBMs. This is known as clawbacking.
PBMs Don’t Serve Patient Needs Well
Clawbacking is detrimental to optimal health and the well-being of our health care programs.
PBMs misinform patients who consider or prefer compounding medications:
- They deny compounding prescription coverage due to FDA guidelines.
- They place at highest tier cost for coverage.
- They push large scale traditional pharmacies.
- They minimize patient options.
- They minimize prescription quality.
With the rising cost of medication and compounding pharmacies consistently offering high quality, custom-formulated alternatives for patients, this provides positive options for many, like Eva.
We may not know where the U.S. health care system is headed, but with compounding pharmacies and doctors who care enough to inform and put patients first, greater well-being moves one step closer.