I worked for a pharmacy benefit manager for 5 years. A PBM is like a health care HMO for medications. The PBM I worked for is one of the top companies in the category in revenues and size. We also had a mail order component where people could have 90 days of medication shipped directly to their house.
I support a public option and even single payer - anything that would defeat the monster insurance companies like I use to work for.
I no longer work there not because my morals kicked in - they actually fired me because I didn't say please or thank you enough.
Our major customer was one of the large insurance companies and we also had many union plans and portion of the Federal Employee Plan.
I can tell you that when Harry Reid talks about a privately run public option - run far away from it as far as you can. Basically big Pharma as well as the health insurance plans want a health care version of Medicare Part D.
That was the big corporate kiss the Bush administration gave Big Pharma to provide medication coverage for Medicare members. It is provided by private companies like the one I worked for. It also has the infamous "doughnut hole" where members must pay 100% of the cost of their meds when they reach a certain level in the middle of their plan. It also included premiums members paid to the insurer and in many cases a deductible of a couple of hundred dollars. Medicare Part D also didn't allow prices to be negotiated.
Medicare Part D became a 3rd of the business at the company I worked for. When General Motors declared bankruptcy, the result was they dropped medication coverage for their retirees - all of them. They then had to sign up of a Medicare Part D plan.
My company also pushed what they called "compliance". Basically if you didn't get 90 day supply of generic medications shipped to your house, you and your family took a bath on the costs of the medications.
But you say you can get those cheaper at Wal-Mart or Kroger through their $4.00 for 30 days and $10.00 for 90 days for most generics?
Yes, but many plans I worked with had a Retail Refill Allowance which doubled your costs if you got your medication filled in a pharmacy too many times - usually more than 3 times.
But if I get them filled under Wal-Mart's program I'm not using my insurance.
Right but Wal-Mart still runs the prescription through the computer system and your PBM still gets a copy of the claim and that $4.00 refill still counts against your RRA so you better hope you can always get it filled at the store for $4.00 or $10.
If you and your Doctor have an agreement that you only want to use brand name medications my company would still call your Doctor and ask them to agree to change to a less expensive drug or a generic. We would accept an office person agreeing to it - someone who may not have even looked at your chart. It is generally legal if not ethical.
My company made more money if people used generics or certain brand name medications that we would get rebates for.
For people who wanted to be able to budget their medication costs each year had a hard time if their plan allowed for "formulary updates" during the year. Some coverage and pricing changed on a quarterly basis with no warning to the member.
The calls I hated the most were from people who had reached their retail coverage limit and were out of medication. They would ask why I was keeping them from their medication and I would have to respond "We aren't keeping you from your medication since you can buy it out of pocket...."
Yes logically they could but if they didn't have the couple hundred dollars for the medication they weren't going to be able to get it.
My company rationed and controlled the medications for more than 65 million people no matter what the Doctor said.
I was reading our company annual report one day since I had some stock options and learned the President had a $27,000 car allowance as part of his income package. For the price of his car allowance he could have paid for another employee like me.
I doubt I would have stayed much longer even if they didn't fire me as the job was getting to me more and more. Having people cry because they can't get a medication would just cut me deeply.
That's probably why I failed to maintain my call quality and was let go - probably subconsciously I needed to leave but couldn't do it myself.
Well to cleanse myself after that nasty confessional I put together this short clip about the Public Option.