Example: PBM rejects Besivance as non-covered NDC, and suggest the of Vigamox, i.e. Brand to Brand switch to gain a rebate when the best product would be ciprofloxacin at $10.00

How is it that rebating to the patient suddenly causes all these problems but the rebating to the PBMs over the last decades did not? The truth is that rebating to the patient or the PBM causes the same problems, and one of those problems is the over use of brand name drugs.

Creating tier copays was a way for PBMs to keep branded drugs on formularies, collect rebates, and still market the appearance of saving the sponsor money.

Now that tier game is being circumvented via consumer rebates; no new problems are being created that did not exist before, it is just that now the PBMs no longer benefit…. the patient does. However just like when the PBMs benefit from coupons and/or rebates………. the sponsor still pays the price of over use of branded medication. Again see example above.

Adam goes to the retail pharmacy, receives a 90 day supply. Adam never refills the script.
Bob goes to the retail pharmacy, receives a 30 day supply. Bob never refills the script.

Adam has a higher MPR than Bob.

Is Adam more adherent than Bob?

I responded that I appreciate that, Adam; you are now including health outcomes in your thought process regarding ROI on the decision of which drug distribution channel to be used. The more you look at health outcomes as part of the cost of distribution the more you and others will see that health care supplied at the community level is by far the most cost effective.

Secondly, however let me “again” point out this study that you liked regarding health outcomes is not a comparison of retail adherence vs. mail order adherence but rather a comparison of 30 day fill adherence vs. 90 day fill adherence.

When you compare a 90 fill at retail vs. a 90 fill at mail order you will see that compliance at retail exceeds mail order; due to convenience, elimination of psycho-social problems, and lack of complexity with local/community 90 day fills. Dayton Adherence Project 2008. We go out and to the studies not Meta-analysis of others work.

In a second rebuttal to an Adam Fein blog where he stated that mail order had better adherence than retail, on 08/11/2011 I stated:

In regards to mail order vs. retail compliance/adherence rates that are circulating on the blogs today 08/11/2011, and I am sure soon to be in the main stream media, I agree with their facts , 90 days’ supply does increase adherence, but disagree with their conclusion.

This study was not a comparison of retail adherence vs. mail order adherence but rather a comparison of 30 day fill adherence vs. 90 day fill adherence.

Now this new study (WHI/Walgreens) on the blogs today backing up the Dayton Adherence projects show that PBMs are not only non-fiduciary towards their clients (See Van Antwerp) but also harmful to their client’s health when PBMs contractually prohibit or dis-incentivize 90 day fills at the local community pharmacies.

Take-Away Points on mandatory mail order

By restricting pharmacy choice and access, mandatory mail appears to cause some
members to discontinue therapy prematurely.

When members choose to discontinue rather than switch pharmacy channels, the unintended
consequence is a reduction in medication adherence and the potential for increased medical expenses.

Individuals without previous use of mail-service pharmacy are particularly sensitive to
Mandatory plan designs and are an important population to target for interventions to support adherence.

Now that is shown that there is no evidence that clinical adherence is improved with mail order, and given the take away points there solid inference that clinical and financial harm is caused by the use of mandatory PBM prescription mail order.

Jim Fields RPh CFO ApproRx