Fall 2006 | Facing the Double-Edged Sword of PBM's / Nancy Diaz

For years, hemophilia factor concentrate has been covered through the major medical portion of your insurance policy. To have a PPO (Preferred Provider Organization) or POS (Point of Service) insurance coverage meant freedom of choice. Regrettably, it seems those days will soon be over.

Under the guise of cost containment, your employers, insurance companies and Pharmacy Benefit Managers, also known as “PBMs” or “Prescription Payers,” are slowly taking away your right to choice. Years ago, factor was covered under the major medical portion of a patient’s insurance policy. However due to the expense of factor concentrates, lifetime caps were quickly met. Over time, factor started to be recognized under prescription drug benefit plans. This was a good thing because most of the plans for prescription drug coverage did not have lifetime caps. At that time, there were no exclusive agreements with any particular providers. You could use any homecare or specialty pharmacy you felt comfortable with, and you did not have to be concerned with using up your lifetime cap. This was a positive step for the coverage of clotting factor medications.

However, what appeared to be a good thing is now a double-edged sword. Over the past few years some of the larger companies have been bought or have merged with PBMs. With the promise of cost containment to your employers, these companies have figured out a way to corner the hemophilia market at the expense of your freedom of choice. Factor is being placed on a specialty drug list by these new conglomerates. They dictate the patient must use a specialty pharmacy formed by these conglomerates to get factor. This forced demand is very frightening. Even if you have insurance coverage that previously allowed you freedom of choice, the same is no longer true for your prescription coverage. The PBMs are now setting their own rules.

Make no mistake – eventually, lifetime caps will be imposed for hemophilia clotting factor under your prescription coverage. In search of lower insurance premiums, your employer is giving insurance carriers too much latitude while your freedom of choice is violated. The pharmacy/home care companies that you have been happy with and that have provided you with good service will slowly be eliminated. These are the same companies that have provided jobs for many within the hemophilia community for years. Without healthy competition between homecare companies, the price of factor to the consumer will begin to increase. This will ultimately have a negative effect on the hemophilia community with reduced services, programs, fundraising and other benefits.

Overall, the main concern of the PBM is to save money. How does this translate for you? Have you ever had your insurance remove certain medication from their formulary that you have been taking? Have they told you to switch to a different medication or pay for it yourself? Is even your doctor powerless when that occurs? What will stop them from doing the same thing with your factor concentrate? At this time, PBMs do not even have to disclose to you how much is charged for your factor. When their mission is complete, PBMs will have ultimate control over what you use to treat your bleeding disorder.

The hemophilia community does have a voice in this matter. If you see that your choices are being reduced or taken away altogether, go to your employer and insist that you want to stay with your current homecare provider. Keep hold of the options you may still have. Once the PBMs start calling the shots, “choices” will be made for you. Regaining control of your medical treatment will be that much harder, if not impossible. Please do not idly sit back and let someone from an insurance company take away your health care rights.

What You Can Do…
We are quickly approaching the beginning of the year when changes to insurance policies occur. Do not be afraid to ask specific questions of your human resources department when you are choosing your insurance policy.

1. Ask if your factor medication is covered under the major medical carrier or the prescription plan.
2. If your primary medical insurance allows you freedom of choice, ask if you will have the same freedom of choice under the prescription coverage.
3. Be specific with your questions when asking about coverage. “How will my hemophilia clotting factor medication be covered?”
4. If the answer to question #3 is prescription payer or PBM, ask if you will be allowed to stay with your current provider.
5. If the answer to #4 is “no”, ask if you are expected to use a specific pharmacy to obtain your factor. Usually, the pharmacy you are expected to use will be an owned/merged company with the prescription payer. (Convenient, huh?)
6. If you find yourself in this position and want to stay with your current provider, go to your human resource department at your place of employment. Find out your rights. Keep in mind, your employer is the customer of the insurance company. They have the power to request changes to accommodate their employees.
7. Ultimately, the medical benefits are supposed to be for you. Speak up! Your employers need to hear you loud and clear.
8. Go to the Hemophilia Federation of America website for more information.
www.hemophiliafed.org/ssp_statement.html

Remember…
• These conglomerates have blanketed several conditions, not only hemophilia. They have promised your employer cost savings across the board. Your hemophilia factor medication is being used as leverage to lower costs for other medications. More than likely, you could actually be paying more for your factor medication because your insurance will be saving a few dollars for other unrelated conditions. This will pose huge problems once the PBMs begin to establish prescription lifetime caps.
• When payments are made through the major medical benefit you receive an explanation of benefits (statement) of what was billed and paid. The pharmacy payer does not supply an explanation of benefits. Therefore, you will not be aware of what you are being charged for your hemophilia clotting factor medication.
• In any business, it is always good to have competition. It keeps the business honest. The mission behind these conglomerates is to eliminate all of the competition. Then what?
• Everyone is concerned with the rising cost of health care. Conglomerates have promised employers cost containment. What happens when all of the “competition” is gone? What happens when your freedom of choice no longer exists? Once the PBMs have a monopoly over the market, there is no telling what will come of their “proposed” cost savings.

To learn more about advocating for your insurance rights, contact your local Bayer representative or the Matrix Public Relations Specialist, Justin Lindhorst at 513-751-2139 to receive a copy of Bayer’s “Advocacy Toolkit.”

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