A small number of pharmacies in the U.S. don't accept insurance and don't do business with pharmacy benefit managers. Opting out of the traditional pharmacy business model allows them to offer generic drugs at a much lower cost to patients, and allows pharmacists to focus on doing their job well rather than having to fill high volumes of prescriptions, the Ohio Capital Journal reported June 22.
For more expensive drugs, such as brand-name and specialty ones, using insurance to pay for them makes sense, since they can cost thousands or tens of thousands of dollars monthly, according to the Journal. But for cheaper generic drugs, opting out of insurance and PBMs can often make the drugs much more affordable for patients. Opting out especially benefits those without insurance or with high-deductible plans.
When HIV drug Truvada's patents expired last year, 11 cheaper, generic versions came to market. But the cash price for the generic version of the drug actually increased at most pharmacies that use insurance and PBMs, according to the Journal. That's because of a complex system of drugmaker discounts to PBMs and nontransparent reimbursements from PBMs to pharmacies,by which pharmacies often lose money.
But at Blueberry Pharmacy outside Pittsburgh, which doesn't use insurance or PBMs, patients can buy a generic version of Truvada for $25 per month, the Journal reported. At traditional pharmacies, patients face a baseline price of $2,100.
In 2019, generics made up more than 86 percent of prescription drugs dispensed in the U.S., the Journal reported.
At Freedom Pharmacy, near Columbus, Ohio, which doesn't use insurance or PBMs, owner Nate Hux told the Journal he charges patients the price he paid for a drug plus a dispensing fee of either $8 or $12, depending on whether it's a 30- or 90-day supply.
"That's what a pharmacist is worth per prescription to make sure they're vetting the prescription properly, to make sure the patient understands how to take the medication properly, to make sure there's no drug-drug interactions, to make sure we call the physician if there's a dose problem. Those are all things that go into every prescription that we do," Mr. Hux told the Journal.
He also said operating outside the traditional business model allows him to not have to fill more and more prescriptions to make enough money to keep the pharmacy profitable.
"All of our profit comes from our services, like checking and vetting out the prescriptions, screening the doses. I can tell you this: The things that you get paid for are what you become good at," he told the Journal.
But pharmacies that opt out of the traditional business model are few and far between. The Journal only found one in Texas, one in Ohio, one near Pittsburgh and one company that operates five locations in Oklahoma.
Greg Lopes, a spokesperson for the Pharmaceutical Care Management Association, a PBM industry trade group, told the Journal that PBMs bring value to all types of drug transactions.
"America's pharmacy benefit managers, PBMs, have a long history of supporting generic drugs to lower prescription drug costs for patients. The key to lowering prescription drug costs is through enhanced competition among brand-name drugs from generic and biosimilar medications," he told the publication.
Read the full article here.