PBM Preferred Networks - Patient Impact
By Gregory K. Shaeffer MBA RPh FASHP
Paying More for Medication
In my last blog I introduced and discussed the concepts of Preferred Provider PBM networks and I focused on the clinical and economic challenges for pharmacies in their choice to participate in the preferred networks.
This blog I will focus on the clinical and economic challenges for patients.
Patients enrolled in preferred provider networks may be given significant co-pay incentives to use only the preferred pharmacies. Some plans entirely block patients from receiving their Prescription benefit when utilizing non-preferred pharmacies. Patients that are required to participate in preferred provider networks, whether it be through financial disincentives or absolute prohibition to maintain their current pharmacy benefit, are at risk. Patients lose their established relationship with their pharmacist and the loss of important pharmaceutical services such as home delivery, compliance packaging, medication synchronization and Medication Therapy Management(MTM) all important to the care of the patient.
Patients who choose to maintain their current pharmacy relationship in a non-preferred network pharmacy could be required to pay significantly higher co-pays for their prescriptions. In the worse cases, patients have no drug benefit, no actual prescription coverage, and are forced to pay penalty fees on top of any fees for whatever special service they are receiving.
Patients face a situation where they must change pharmacies and lose vitally important services to be able to afford their prescription drugs. This can disrupt the caregiver-patient relationship and place patients at risk. The alternative is to pay much higher out of pocket copayments for prescription drugs. Either way, the pharmacy’s customer base begins to erode.
Data from IMS indicates that approximately 25% of prescriptions written are never filled. Hospitals are faced with potential Medicare economic penalties for certain diagnosis’s if the patient is readmitted to the hospital for the same discharge diagnosis. The strategy to mitigate this exposure due to patient non-adherence is to ensure that patients leave the hospital with their discharge medications is a vital component to reduce hospital readmissions.
Closed pharmacy networks can complicate this care transition for patients who are hospitalized and could otherwise receive their discharge prescriptions from the hospital ambulatory pharmacy thus decreasing the potential for readmission and hospital financial risk.