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    High Tamiflu Costs Hurting Patients and Pharmacists

    Many pharmacists claim low reimbursement rates for Tamiflu and many patients are being left with high costs.


    While a majority of independent community pharmacists say PBMs and insurers are not covering Tamiflu prescriptions — or not lowering their co-pays for the expensive drug — during the worst influenza season in several years, at least one PBM disputes that claim.

    In NCPA’s late January survey of independent pharmacy owners, 88% said that in the past 60 days they experienced multiple incidences of reimbursements for Tamiflu or oseltamivir at rates below the pharmacy's acquisition cost for the medication.

    “In a situation like this, the PBMs should do the right thing and allow coverage for whatever type of Tamiflu is available: capsules, suspension, or compound,” Eric Larson, PharmD, owner/president of Prescriptions Unlimited in St. Cloud, FL, tells Drug Topics.

    Related article: Flu Vaccine Could Provide Long-Lasting Protection

    Many of the pharmacy owners also reported difficulty in acquiring various forms of Tamiflu or oseltamivir (capsules, suspension) in the past 60 days, according to the NCPA.

    "Many PBM contracts require pharmacists to dispense to a patient a medication they have in stock, regardless of whether it is at a loss," says NCPA CEO B. Douglas Hoey, RPh. "As a result, many community pharmacies are having to eat the loss in order to see that their patients are cared for during one of the worst flu seasons in years. Some respondents are citing losses in excess of $60, even $70 per prescription.”

    Pharmacists are not the only ones having problems paying for the treatment. Larson recalls that during the H1N1 outbreak in 2009, there was a shortage of Tamiflu suspension and the compound was mandated to be covered. However, this year, some insurers are not covering the script — or are not lowering copays that are as high as $150.

    “A generic [Tamiflu] copay should be a lower co-pay. Why would insurance companies put Tamiflu on their high tier? Why make it so expensive for patients?” Larson said.

    In some cases, flu patients who do not pick up their Tamiflu because of costly copays have died. Eighty-four children have died from influenza since October, according to the CDC. In addition, adults such as Texas teacher Heather Holland, 38, died from the flu after deciding not to pick up her Tamiflu script, which was $116 with her insurance co-pay, Newsweek reports.

    “I have had a lot of patients who couldn’t afford the co-pay, but I am bound by contract with insurance companies, so I cannot offer them a lower cash price. Unfortunately, they have left without the prescription, and it is typically pediatric scripts they are not picking up,” Larson said.

    Related article: How community pharmacies are affecting flu vaccine rates

    However, Express Scripts says it is doing everything it can to make Tamiflu more affordable for patients. As the flu season began to worsen, the PBM moved branded Tamiflu to preferred brand status on its commercial and Medicare standard formularies “to make the medication more accessible and affordable,” Jennifer Luddy, a spokesperson for Express Scripts, tells Drug Topics. Generic Tamiflu is a covered medication on both formularies.

    “That said, each plan’s coverage and copays are different, and some plans have their own formularies or coverage rules with regard to this medication,” Luddy adds.

    In addition, Inside Rx, a subsidiary of Express Scripts that offers discounts on brand and generic medications for people without insurance or who have high out-of-pocket costs for their medications, added branded and generic Tamiflu to the list of drugs available for a discount. 

    “It is also important to note that drug prices are not set by PBMs; they are established by the drug maker,” Luddy says.


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