Berks County Medical Society Medical Record Summer 2019 - 12

M e d i c a l r e c o r d f e at u r e

Perspective of
a Pharmacist
by Eric Esterbrook, RPh, Esterbrook Pharmacy

O

nce a prescription is delivered to a retail pharmacy, what
happens? Does the patient get the prescribed medication? If
not, why? What are the barriers?

When a pharmacist receives a prescription, they will typically
enter the information into the pharmacy's software system. Next
a clinical check will be performed assessing for drug interactions,
allergies, and therapy duplications and to ensure that the drug,
dose and duration are appropriate. It is then billed to the patient's
insurance plan or filled as a patient pay. The medication is then
counted, dispensed and ready for pick up or delivery. In a perfect
world this is the case every time. Unfortunately, we don't live in a
perfect world.
There are numerous reasons why a patient may not receive their
prescription. Cost is the number one reason. I say this because when
a prescription is not covered by insurance the patient's only option
is to pay out of pocket for the medication. Almost always the cost is
too high. Drug availability is another common reason. There have
been more issues in recent months with the availability of common
medications, a distressing trend that does not seem to be ending.
A pharmacy staff member will know instantly if a prescription is
covered or not. If the prescription is not covered, there are a number
of possible reasons. Sometimes it is simple, for instance: "refill too
soon." This means the prescription is covered but the patient must
wait until most of their previous prescription is used. A 30-day
prescription can be filled when the patient has 3-5 days left. Most
pharmacy staff will place a "refill too soon" prescription on hold in
their software until the patient is ready.
The example above is probably the only simple rejection we get
from insurance plans. The most common are "not covered" and

12

|

www.berkscms.org

"prior authorization." This is a complicated web of confusion that
does not follow logic. With the number of different insurance plans,
and options within those plans, it is nearly impossible to keep track
of which medications are covered or require prior authorization.
I would like this opportunity to shed some light on and briefly
explain PBMs, which is an acronym for Pharmacy Benefit Managers.
These companies are the "middleman" between pharmacies and
the plan sponsors or payers. Originally, PBMs would handle
prescription insurance transactions. 20+ years ago they helped to
automate the billing process. I still remember when we had to fill
out a paper claim for every prescription. It was very time-consuming,
and the PBMs offered a solution to electronically send the claims.
Express Scripts, CVS Caremark, OptumRX are the top three PBMs.
They control 85% of the marketplace, which affects over 253 million
American lives. They have very little regulation and most patients
and legislators do not understand them and how they work. The
PBMs have exploited this lack of transparency, restricted choices for
patients, and unfairly ruined competition in the marketplace.
Per an article in The American Prospect: "Over the past 30 years,
PBMs have evolved from paper-pushers to significant controllers
of the drug pricing system, a black box understood by almost no
one. Lack of transparency, unjustifiable fees, and massive market
consolidation have made PBMs among the most profitable
corporations you've never heard about."
PBMs also have control over which pharmacies will be included
in a prescription plan's network and how much the pharmacies will
be paid for their services. Most encourage plan sponsors to require
plan members to use a mail order pharmacy - which is usually
owned and operated by the PBM - for maintenance and specialty
medications.
http://www.berkscms.org
Berks County Medical Society Medical Record Summer 2019

Table of Contents for the Digital Edition of Berks County Medical Society Medical Record Summer 2019
