Pharmacy Benefits

In the last decade or so, insurance companies and TPAs for self-funded plans have launched a campaign of what is called “brown- and white-bagging.” In essence, these growing programs work on the principle that, if chemotherapy and biological drugs are dispensed by a specialty pharmacy instead of the traditional “buy and bill” done by the physician's office, it would provide better access for patients and eliminate the incentive of over-utilization by doctors. When Aultcare sought the opinion of Gabrail Cancer Center leadership about this idea 10 years ago, we had some (well, many) concerns about the validity of those claims made and they agreed. I would say that was smart of the Aultcare leadership, because what we see (and what studies are showing) is contrary to what has and is being promised.

Going through evidence and studies might be a cumbersome and complicated process, but examples of personal experience should clarify the pitfalls of this failing system. Here are just few examples of hundreds that we have encountered in the last several months at our center.

A patient receiving chemotherapy for cancer of the pancreas requires expensive biological agents to raise the blood count (Leukine and Procrit). We called the specialty pharmacy that the insurance company mandates we deal with for brown/white bagging. We ask for the biological agents and they encourage shipping a 3-month supply (worth $50,000+).

In this case, the patient developed an allergic reaction to Leukine after receiving only one injection. We cannot give it anymore to the patient and we cannot ship it back (that is a policy for prescribed medications). How convenient! Of course, the same policy would not allow us to give the drug to other patients, so we have only one option…throw it in the biohazard waste.

So, now we need to give an alternative drug to raise the white blood count (Neupogen) which is another $20,000 worth of drug. How nice for the pharmacy! They cashed on all this and so did the drug companies. By the way, I forgot to mention, guess who paid for the wasted drug? The employer did, not to mention the patient who paid their copay as well. The patient also needed Procrit for the anemia and, of course, a 3-month supply was shipped (which, by the way, was a very short-dated supply).

The patient needed only 3 of the 20+ vials shipped. The rest goes to waste, as the rules require. Who paid for it? The employer.

There is one simple principle in economics: There is only one person who cares the most about your wallet…you!

You need to take charge! The savings are huge and the potential waste imposed on you now is more than what you know. When you inquire, you will know; and, when you know the magnitude of the financial damage, you will conclude that you need to take charge. We can help through EHCS.