Federal government billed
hundreds more than market value for prescription
By Lee Zurik and Cody Lillich | January
13, 2020 at 12:02 PM EST - Updated January 13 at 1:10 PM
GONZALES, La. (InvestigateTV) - Two Louisiana
men - one a patient, and the other a pharmacist - said they found medical waste
that is costing every taxpayer in the country.
Joel Siedel’s wife, Dianne, is battling
amyotrophic lateral sclerosis, or ALS. Doctors prescribed her a drug called
Riuzole.
“It’s supposed to slow down the progression of
ALS,” Siedel said.
For the first six months of the year, Siedel
ordered his wife’s medication through the mail via CVS/Caremark.
“There was no copay,” Siedel said.
But when he looked over his explanation of
benefits, or EOB online, a number jumped out at him.
“How do you justify that?” he asked.
While Siedel paid nothing, the 90-day supply
of the medication cost their insurance plan $1,700. Their insurance is provided
through Medicare, which is funded by taxpayers.
Siedel drove to an independent pharmacy in
Gonzales and found a startling difference. The same drug there was available
for $170.
“It’s all about the money, It really is.
There’s no reason this should be happening,” Chris Dupre, a pharmacist in
Gonzales, said. “They were charging ten times plus to insurance, Medicare Part
D, funded by taxpayer money.”
There were also hidden costs in the Siedel’s
medication since the government structures payments in the Medicare program.
While initially, patients pay little to no copay, when the total cost of
medication reaches $3,820, the patient hits what is referred to as the “Donut
Hole" where they pay more money for prescriptions.
Each 90-day supply of that ALS drug for the
Siedels cost the Medicare plan $1,700. So after six months, that drug alone
would count for $3,430.50. Once they hit $3,820, more comes out of their
pocket. Other medications for the Siedels easily pushed them into the “Donut
Hole” in March of 2019.
“I feel like she got ripped off," Siedel
said.
“I call it excessive profiteering because
that’s what it is,” Dupre said.
Dupre has been a pharmacist for 25 year and
said there’s little the taxpayer can do about it because of safe harbor
protection laws passed by Congress that limit the scope of what these companies
are forced to share on prices and costs.
“It’s illegal to find out if they’re doing
anything illegal,” Dupre said.
Siedel said he has probably used the CVS
mail-order service for the last time, instead opting for companies that are
more transparent in their pricing.
In response to this story, CVS/Caremark told
by email:
The ALS medication is covered by the patient’s
Medicare Part D plan, for which CVS Caremark is the PBM, and the patient’s plan
provides an option to receive the medicine through mail order in addition to getting
a medication filled at retail pharmacies. The patient’s plan has a zero dollar
co-pay when using CVS Caremark mail order and up to a $30 copay at any
participating retail pharmacy for a 90-day supply for this drug. Plan members
can choose whether to use a mail order or a retail pharmacy, and it’s unclear
why this patient switched from mail to retail, which incurred an additional
co-pay cost.
CVS also blamed the pharmacy for the difference
in price, writing:
Our reimbursement to pharmacies for this medication
is an accurate reflection of its cost in the market. Based on our records of
the transaction and our conversation with the pharmacist, the pharmacy first
submitted a price that was about 10 times more than the cost, realized the
error and resubmitted a claim about 10 times lower than the cost. In both
cases, the pharmacy acknowledged to us that the information they input was
incorrect. We will work with this pharmacy to correct the claim so that they
are reimbursed appropriately.
Copyright 2020 Gray Media Group, Inc. All
rights reserved.
No comments:
Post a Comment