Bring your own stamp or what’s so special about Specialty Pharmacy?

By Trent McLemore

I was walking into the house one Thursday night, around 8:30, while on a conference call with the other Board members of the Alabama Independent Pharmacy Alliance (AIPA). 8:30pm is the only time we could meet and discuss protecting Alabama’s Independent Pharmacies, since we’re all unpaid volunteers with day jobs. Our discussion focused on independent pharmacies being paid fairly when SB 252, the Community Pharmacy Relief Act, is fully implemented on October 1. AIPA was crucial in defeating the Big Pharma Insurance company’s lies about a $10 “prescription tax” back during the Alabama legislative session this past spring, but these Pharmacy Benefit Managers, or PBM’s for short, are always looking for new ways to undercut the competition while steering patients to their own pharmacies.

I’m sorting through the mail, listening to the others talk, when I interrupted everyone and said, “you guys aren’t going to believe this.” It was a blank form that a PBM-owned specialty pharmacy had sent to my daughter for us to fill out and *mail* back in the provided envelope (stamp not included). At the very bottom of the form was the question ‘Would you like to speak to a pharmacist regarding your medication?’ So, you’re telling me if I want to speak to a pharmacist at this “special” mail order pharmacy, I must write them a letter? Is this seriously the expert level of care that only the PBM-owned specialty pharmacy can provide?

My PBM requires that I use their “specialty” pharmacy because a “normal” pharmacy is incapable of filling prescriptions for these “special” medications. My second born daughter, baby Ruth, was recently prescribed a medication to help with her very itchy skin. This medication could only be filled at “specialty” pharmacy sending out letters to counsel it’s patients.

Who made this determination? My insurance company. My insurance company (and their pharmacy insurance subsidiary) claim the eight pharmacies I am responsible for- all of which are fully accredited Specialty Pharmacies- are not qualified to dispense this medication…at our SPECIALTY Accredited pharmacies. Did I mention we are the largest group of fully accredited specialty pharmacies in Alabama? I’m not sure that matters. At least, it doesn’t to my insurance company. They said I had to get this medication from their mail order Specialty pharmacy. Why? I’m not sure. Since I started working for my employer, we’ve filled prescriptions for this exact medication over 17,000 times. I’ve personally administered this drug over 100 times to patients who did not feel comfortable injecting themselves (and understandably so…it’s scary!).

What makes a drug, “special?” Well, in a word, expensive. If a baby drug is lucky enough, works hard, and is given a list price of thousands of dollars, then it may get to grow up to be a “Specialty” medication. These drugs have big price tags so that the PBM can strongarm the drug maker into paying them off for putting it on their formulary. In most circles, this would be called a “kickback” and would be illegal. Frowned upon, even. Not for Big Pharma Insurance! Nope. They have a special exemption from the Federal government to accept these bribes rebates from Big Pharma.

Back to baby Ruth: Her momma and I tried everything we could before resorting to giving our child an injection. Even though I:

- am a pharmacist, 

-have dispensed this medication thousands of times,

-have seen this drug work tremendously well for kids as young as 6 months…

 …it’s just different when it’s your baby. We tried eliminating every allergen imaginable. I swear that girl lives on “milkshake” which is some kind of chocolate milk made from a pea. I didn’t even know you could milk a pea. We tried emu oil and all the steroid creams and ointments until her skin started to blotch/bleach and finally we knew it was time. Baby Ruth needed the injection. We want her to feel better. To sleep a full night without clawing the insides of her ankles to a bloody mess.

We made the trek down to the allergist in the land of corporate high rises, under the shadow of the Vulcan. The physician and nurse practitioner went over all the side effects, how to give the injection, what to expect, etc. At some point I might have said, with the utmost obnoxiousness, “Actually I’m a pharmacist and I’m very familiar with this drug.” What a nerd. My poor wife. My poor daughters when they get older.

So, the nurse practitioner administers a trial dose of the medication to baby Ruth. Baby Ruth cried for a minute but got over it once someone mentioned a chest full of toys. The prescription was sent directly to the mail order pharmacy because…the allergist knows…and I know. There’s a huge racket being ran under the guise of “Specialty” drug designations. There’s nothing special about “specialty” medications other than the money PBM’s launder through specialty drugs. Naturally, PBM’s would prefer to keep any profit for themselves and then with a smile, lie to the face of employers, telling them, “We’re saving you money. Trust me, bro.”

This past spring, AIPA fought to stop the mass export of prescription revenue out of state to PBM-owned pharmacies. The state employee’s insurance plan? Their “specialty” medications are shipped in from Indiana and Florida. Do you have the same commercial insurance that 86% of our great state has? Are you a teacher? You’ll be getting your “special” drugs from Pennsylvania, Texas, or Florida. Specialty medications account for HALF of PBM profits. There is real savings to be had in Specialty for employers, taxpayers and patients. Big Pharma Insurance fought back to exclude specialty from SB252, and we all know why it was kept out of the bill. Money.

So, I’ll be sitting here for the rest of the day, waiting on a shipment to come in for a refrigerated medication, when there are 5 boxes of the same drug sitting in a pharmacy I work for that I can’t fill. Why? Because an insurance company knows better than I do on who is qualified to fill a prescription. Someone who takes zero liability, didn’t go to school, doesn’t know the patient or physician. Maybe use local pharmacies should start requiring our patients to write us a letter when they have a question instead of calling or coming to see us. That seems to be the standard of care that Blue Cross and Accredo think is acceptable.

We are all just numbers to Big Pharma Insurance. To me, it’s my baby Ruth. There is no one more qualified to take care of my daughter than me. Something must give. We must push back. The system is crumbling and I’m seeing it happen both as a pharmacist and a patient. If we don’t speak up, it will just continue to get worse. Premiums and deductibles will continue to rise. Just remember to bring your own stamp.