CVS sometimes forces people to use its pharmacies. Now the Supreme Court will weigh up

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CVS Health and other large corporations often use their pharmacy middleman subsidiaries to force people to source the most expensive drugs from their own mail order pharmacies. Some call the practice “patient guidance”.

CVS and companies like UnitedHealth and ExpressScripts / Cigna say the agreements save patients money. But asSome patients, oncologists, and other health care providers say it is life threatening.

Now the US Supreme Court is ready to weigh itself. In just over a month, he’ll be hearing arguments in a California case where AIDS patients claim the practice discriminates against them.

Known as “pharmacy service managers” or PBMs, middlemen work with insurance companies or government programs such as Medicare and Medicaid to facilitate transactions in prescription drugs. They negotiate discounts with drug manufacturers, decide which drugs are covered and how much pharmacies that dispense drugs as part of their health plans will be reimbursed.

In the California case, however, it is controversial how PBMs structure their pharmacy networks.

Each of the three major PBMs is affiliated with a major insurer, and each is part of a company that is among the 13 largest in the United States. And it is estimated that the combined PBMs control well over 70% of the pharmacy middleman market.

In addition, they often compete directly with the retail pharmacies whose reimbursements they control. CVS owns the largest retail chain in the country, and each of the big three owns a mail order pharmacy selling “specialty drugs” – the most expensive class of drugs, which can cost up to $ 100,000 a year.

Increasingly, the big three PBMs have stated that they don’t cover super-expensive specialty drugs when patients get them in their oncology centers or AIDS clinics. It is increasingly the case that PBMs can only cover them if patients receive them in the mail from a PBM’s own pharmacy.

Critics say it’s about increasing profits, but the PBMs claim that they are doing it to help their customers.

“To keep costs down, the draft plans offered by pharmacy service managers often impose the toughest restrictions on ‘specialty drugs’,” said CVS in its petition asking the Supreme Court to open the case. “There are special shipping, administration, or storage requirements for these drugs; treat rare diseases; or are very expensive. “

It added: “Pharmacy service administrators often control the disproportionate cost and complexity of specialty drugs by entering into contracts with specialty pharmacies that have expertise in the ‘unique handling, storage and dispensing’ requirements of these drugs. Pharmacy service managers are increasingly relying on specialty pharmacies that deliver by post. “

Cancer and HIV patients say mail order doesn’t work

However, many patients complain that mail order is significantly inferior to the services they receive in person from pharmacists, especially when they have complex medical conditions that require equally complex drug treatments.

In 2018, Elvin Weir, a now deceased cancer patient, described to The Columbus (Ohio) Dispatch how late or incorrectly filled mail order cancer prescriptions had often delayed the rest of his treatment as his disease worsened. And officials at oncology centers said the deal disrupts collaboration between their pharmacists and oncologists in treating conditions that can not only be complex but change rapidly.

Plaintiffs in the original California case argued similarly.

“For people living with HIV / AIDS, strict lifelong adherence to antiretroviral therapies (ART), consisting of complex combinations of drugs consumed on a daily basis, is vital and can literally be a matter of life or death,” wrote AIDS Healthcare Foundation in a friend-of-the-yard briefing.

“For people with HIV / AIDS, so-called specialty pharmacies and pharmacists who focus on HIV / AIDS and personal treatment offer demonstrably better care than mail-order pharmacies and retail pharmacies,” it continues. “Forcing people living with HIV / AIDS to only use mail-order pharmacies guarantees poorer care and poorer health outcomes, and discriminates against disabilities in both intent and effect.”

A panel of the U.S. 9th appeals court said last December that the lower court in the CVS case, among its mistakes, failed to recognize that face-to-face interactions with pharmacists were part of the benefits plan members are entitled to.

The Ninth Ward ruled that CVS’s mail order policy may discriminate against disabled people because it “places different levels of stress on HIV / AIDS patients based on their unique pharmaceutical needs. Specifically, they claim that changes in drugs to treat the constant mutation of the virus require pharmacists to screen all drugs in an HIV / AIDS patient for side effects and adverse drug interactions, a benefit they no longer receive under the program. “

CVS argues that policies are not deliberately discriminatory

CVS, in its appeal to the Supreme Court, denies the plaintiffs’ legal argument that the Mail Order Directive is against the law because it has “various effects”.

In other words, AIDS plaintiffs say that even if at first glance the directive applies equally to all, it is still illegal discrimination if it is discriminatory effect against part of a protected group: the disabled. CVS, on the other hand, argues that as long as his guidelines are not intentionally discriminatory, they are fine.

The law advises recipients of federal funding that willful discrimination is illegal, the petition said. “On this basis, schools cannot discipline students with attention deficit disorder any harder. Cities cannot target target group housing for people with disabilities with uniquely burdensome zoning requirements. Employers cannot refuse to hire a person simply because they are in a wheelchair. And health plans and all others that are subject to (federal health laws) cannot exclude patients with disabilities simply because of their disability. “

“Courts do not need to rewrite (the law) or introduce a non-existent standard with varying implications to achieve the goals of Congress,” argued CVS.

The health company found that the appellate courts had different views on the matter. This is believed to be the dispute the Supreme Court is trying to resolve by retrying the case.

Oral arguments are scheduled for December 7th.

About this story

This story was originally published by the Ohio Capital Journal, which is part of the States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c (3) public charity. The Ohio Capital Journal retains editorial independence. If you have any questions, contact the editor, David DeWitt: [email protected] Follow the Ohio Capital Journal on Facebook and Twitter.

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