Pharmacies, drug companies, and pharmacy benefit managers have all been exposed in the media for unethical practices. With so much money at play, some entities are doing all they can to maximize their revenue. It is crucial National CooperativeRx works to identify products and service providers that may result in low value and higher costs to our members.
This means using our clinical experts and our innovative programs to manage high-cost/low-value medications and save millions of dollars from going into the wrong hands.
Pharmacies
Our in-house pharmacists continue to notice some disturbing trends as part of our high-dollar claim review processes for non-specialty and specialty drugs. Unusual dispensing patterns by some pharmacies are among those trends, leading our pharmacists to investigate further. Their findings have identified that in some cases participants receive product(s) that were not requested.
In other cases, our pharmacists have identified claims that were billed to the pharmacy benefit of participants without their knowledge and no product was received. We continue to work closely with CVS Caremark’s pharmacy network and audit departments to address fraudulent activities like these, mitigate such actions in the future, and help ensure plan sponsors avoid unnecessary expenses from these outlier pharmacies.
Drug Companies
Did you know some drug companies will take two generic drugs and combine them into one pill, then charge brand drug pricing? For example, a person could take ibuprofen and an acid controller for less than $50 over the counter (>90 pill quantity). Or that person could take Duexis. It has the same ingredients, but for the convenience of taking one pill instead of two. Brand name Duexis costs around $3,000, or its generic alternative costs around $1,000 (90 pill quantity).
U.S. health care spend grew 4.1 percent in 2022, reaching $4.5 trillion or $13,493 per person.1
Staying on top of pricing schemes like these is a full-time job. The development of National CooperativeRx fraud, waste and abuse programs and services helps keep high-cost/low-value medications off our members’ formularies.
Pharmacy Benefit Managers
National CooperativeRx partners with CVS Caremark because they do many things well. However, with 89M² plan members, CVS Caremark simply cannot provide the personal level of service that our members deserve. This is where National CooperativeRx steps in to provide additional service, support, and savings.
Plan sponsors with National CooperativeRx generally see lower per-member-per-year (PMPY) spend over their peers who are with CVS Caremark directly. Benchmark comparisons typically show a difference upwards of 15% before rebates. Our lower PMPY spend is due to the added oversight and value National CooperativeRx provides.
Sources
Historical. CMS.gov. https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/historical
About Us | CVS Caremark. https://www.caremark.com/about-us.html
