Specialty Pharmacy Scam - Same Drug Ranges from $37.41 to $2,172

hello this is Dr Eric Bricker and thank you for watching a healthcare Z today's topic is generic specialty medication scam revealed that's right today we're going to talk about a scam in generic specialty medications and it's specifically around a medication called Tech federa now Tech federa is the brand name of a medication that's generic name is dimethyl Fumarate and it is a medication for multiple sclerosis and the brand name Tech federa became available as a generic towards the end of 2020. so now it's available as dimethyl Fumarate you take it as a 240 milligram pill twice a day so it's still considered a specialty medicine medicine okay so it's even though it's a pill on in a person's prescription benefits through their employer it's typically still considered quote unquote specialty pharmacy now one would think that the generic dimethyl Fumarate would be very inexpensive right brand name it was very expensive now that it's generic great we can save a whole bunch of money so let's look at the cost of the generic dimethyl Fumarate okay and this is through GoodRx which actually uses diff uh multiple different pbms on the back end and you don't use your insurance you just pay cash for it but they're still running it through pbms on the back end now isn't this interesting so HEB which is a big grocery store chain in Texas the cost is 37.41 for a month supply okay giant which is big in the Washington DC area 39.21 Publix for all of you in the south forty dollars 41 cents shop right in the Northeast 88 dollars seven cents and then for those of you in the Chicagoland area Jewel Osco 104.90 okay great sounds pretty good now let's look at some other locations again through GoodRx Costco it's a post things are supposed to be inexpensive at Costco right Costco the lowest price right Costco one thousand five hundred dollars Walmart things are supposed save money live better at Walmart right Walmart 1593 dollars Walgreens two thousand eighty six dollars again this is for a one month supply if you want to and you gotta take this every day so for a year you take all these numbers you multiply them by 12. that's what you got to spend CBS two thousand one hundred seventy two dollars this all came about because I was looking at an employer's Pharmacy spend recently and they were spending hundreds of thousands of dollars on dimethyl Fumarate and they were getting it all through the mail order Specialty Pharmacy from their PBM remember the big three pbms own specialty pharmacies that the members can get mail order through that Specialty Pharmacy it's supposed to save you money right guess what the PBM Specialty Pharmacy prices were in line with this side over here in thousands of dollars a month not in this side over here in 37 a month so this is a huge scam this is a commodity the dimethyl fumar rate for thirty seven dollars in the dimethyl fumerate for 2100 it's the exact same pill Dr Reddy's is one of the big companies globally that makes the generic version of this okay this is a commodity if one organization is charging two thousand dollars and another organization is targeting 37 then the organization that is charging the two thousand dollars they're adding no value it's a commodity okay so let's down for an employer okay so multiple sclerosis Ms neurological disease is actually an autoimmune disease it's filled with a sporadic neurological deficit sometimes the person can be blind they can lose bladder control they can have weakness they can lose the ability to walk so it affects all over your nervous system and it comes and goes it's an incredibly um it's a very challenging disease I've treated many patients with multiple sclerosis over the years now typically it strikes between the ages of 20 and 50. so the employed population right if there's a million people in America one million people that have multiple sclerosis well there's about 203 million Americans that are between the ages of 18 and 65 would be an adult who might be on an employer-sponsored plan so if you do the ratio that means that there's going to be one person with Ms out of every 203 adults between the ages of 18 and 65. so if your ratio is 1 to 203 if you're an employer within a thousand adults on your plan that means you probably have five people on your plan with MS and Tech federa dimethyl fumerate is a very common medication for Ms so if you've got five people with Ms that means that if they're go if they're getting it through their PBM Specialty Pharmacy or at one of these places like Costco Walmart Walgreens or CVS that means that that employer is spending approximately 137 excuse me 130 000 a year for those five patients just for their dimethyl fumerate whereas if let's just say they you know on average say they got it for 50 bucks not for 37 not for 88 but let's just say they got it for 50 a month that would cost them about three thousand dollars per year that means that this employer is spending an extra hundred and twenty seven thousand dollars on a scam okay likewise if the employer has 10 000 employees that means they likely have 50 employees with Ms which means they're probably spending about 1.3 million dollars on dimethyl Fumarate where they really shouldn't be spending about 30 000 on dimethyl fumar rate so again they're spending 1.27 million dollars essentially on a scam and so what is something that an employer can do let's be practical about Solutions here like don't cover dimethyl Fumarate if you're a self-funded employer be like we're done we don't want your PBM quote-unquote discounts anymore we're just not going to cover it okay that doesn't mean you're leaving your patients with MS um out to dry you just say to them look just just submit your receipt and we'll give you all the money for it we'll give you the full 37 we'll give you the full 88 dollars we'll cover it completely shoot just write them a check for three grand and be like look call it a day we'll just give you three grand to pay for your dimethyl fumar rate go forth and find a pharmacy use your good RX discount Fantastic look at there's a lot of these programs for lowering Specialty Pharmacy costs where you you use you don't cover it with the plan but then you use a patient assistance program you don't need a patient assistance program to get dimethyl Fumarate for 39 bucks you don't need a patient assistance program you just use the GoodRx app okay so one would argue that if you listen everyone who works in employee benefits an employer-sponsored plan this should not be news to any of you if you are a director of benefits you should know this and if you don't know this then you need to ask your benefit consultant why you need to ask your Pharmacy consultant why why is some random doctor on a video telling you about this you should already know about this and that's my point for today thank you for watching a healthcare Z

Channel: AHealthcareZ - Healthcare Finance Explained

Views: 3,547

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Id: TlUyn6yaJOE

Length: 7min 30sec (450 seconds)

Published: Mon Jun 26 2023