When I wrote about Lipitor generic costs recently, I got some interesting emails. One was from Marian in Phoenix who questioned why she couldn’t get the generic through her Part D plan. Another was from an organization called Pharmacists United for Truth and Transparency (PUTT).
I had a long talk with Dave Marley, the president of PUTT, and he told me some very interesting things about how Part D and employer drug plans work – and how they don’t always work to the benefit of Medicare beneficiaries or people with employer coverage.
PUTT has over 900 members, most of whom are owners of independent pharmacies. According to their website, PUTT is “an independent watchdog organization dedicated to exposing the role Pharmacy Benefit Managers (PBMs) play in driving up prescription drug costs for consumers and employers.”
Pharmacy Benefits Managers (PBM)
PBMs are companies that manage pharmacy benefits for employers and insurance companies. Mr. Marley says PBMs worked with Pfizer to keep Lipitor sales flowing even though the generic would have saved employers and insurance companies millions of dollars.
From November 2011 to June 2012, Pfizer paid rebates to PBMs and Medicare Part D plans for each Lipitor prescription filled. In some part D plans, the co-pay for Lipitor was reduced to the generic co-pay of $8 to $10. However, up until June 1st, most plans I looked at on Medicare.gov were still charging the $40-$45 brand co-pay.
Some seniors like Marian, who wrote me about her Cigna plan, paid a $15 generic co-pay and were provided with Lipitor. But while Marian got a good deal up front, the $150 retail cost for Lipitor went into her Part D account and put her closer to the donut hole.
Mr. Marley, the president of PUTT, said, “Pfizer says, they reduced costs for Lipitor users – but nobody’s price was reduced. Lipitor’s price actually went up due to the rebate scam”. He added, “Because Medicare turned over Part D to for-profit insurance companies, seniors are at the mercy of those companies without proper oversight. Oversight of Part D is atrocious.”
How is Part D paid for?
Part D is mostly paid for by Medicare, at a cost of more than $60 billion a year. 75% of this money is spent on brand drugs, even though most people take generics. Brand drugs are often ten times more expensive than generics. Part D plans are paid between $2,000 and $2,300 per year per person enrolled with them.
Part D plans also get “risk adjustments”, or higher payments for people who have high drug costs. If a person enrolled in a Part D plan takes no drugs, the plan still gets paid. So it’s a no-lose situation for insurance companies that run Part D plans.
Mr. Marley pointed out that Part D plans, in addition to payments from Medicare, get rebate money from Pfizer and other drug companies. Those rebates discourage Part D plans from switching to generics. According to Mr. Marley, “Rebates are a fools gold in the absence of price controls. Drug companies figured rebates cost $20 billion, so they just raised the prices by $20 billion to cover their costs”.
The New York Times wrote about efforts by Pfizer Inc to keep making money from Lipitor as the generic, Atorvastatin, came to market. Here are some excerpts from the November 29, 2011 article:
Some deals require pharmacies to reject prescriptions for low-cost generics, starting Thursday, and substitute a discounted name-brand Lipitor. Some deals have blocked generic makers from mail-order services that account for an estimated 40 percent of all Lipitor prescriptions.
….The memo, from CVS/Caremark, a pharmacy benefit management company, and dated Monday, notified pharmacies that the generic form of Lipitor would not be covered for 29 prescription drug plans it managed for Medicare Part D. Instead, any prescription claims for generic atorvastatin will be rejected with a notice saying: “Brand Lipitor will pay at generic co-pay.”
The company’s memo did not disclose the financial terms.
….The government may receive the rebates that drug manufacturers pay to benefit managers and insurers if they are fully disclosed and characterized as rebates, not fees, according to a March report by the Office of the Inspector General for the Department of Health and Human Services. But benefit managers’ records may not be accessible or auditable, it added.