Exploiting People with Obesity Through Abusive Copays
Some pharmacy benefit plans have taken a dark turn when it comes to obesity medicines. Let’s not sugarcoat it. They are exploiting people with obesity through abusive copays on drugs like Wegovy and Ozempic – two brands of semaglutide. These PBMs pretend they are covering part of the cost of the drug. But in fact, they’re charging a “copay” that exceeds the net price that pharmacy benefit managers (PBMs) typically pay for them.
So no, this is not a copay. It is profiteering by a PBM. Even calling it a copay is dishonest. Because a copayment is “a contribution made by an insured person toward the cost of medical treatment.” The whole essence of copayment is to pay part of the cost for a covered service. Not the whole cost plus a markup to add to a PBMs profits.
The Case of a Federal Employee on Blue Cross Blue Shield
Federal employee health benefit plans are required to cover obesity medicines. So the case of Debbie Halstead, as reported by USA Today, offers a good illustration of what’s going on.
Halstead has done well on Wegovy, reducing her weight enough to have a big effect on her blood pressure and arthritis in her knees, and has restored her to an overall sense of “feeling much, much better.”
But starting on January 1, her “copay” for this very effective treatment will shoot up from $25 per month to $713.
We call this profiteering because the average net cost of drugs like Wegovy is more like $500 per month. Not the $1,300 list price that the media often quotes. It turns out that when it comes to purchasing drugs, the process is a lot like buying a car. Nobody pays list price. That is, unless you are a patient without insurance. Then you get shafted.
Yes, drug pricing is screwy in the U.S.
Abusive Insurance Practices
This kind of behavior is why we are living through a convulsion of anger with health insurance. It’s not hard to find other examples.
For instance, Anthem Blue Cross Blue Shield floated a proposal to cut off anesthesia for procedures that went longer than average. They were simply going to refuse to pay. “Sorry, Mrs. Smith. Your procedure is taking longer than we thought. But your insurance won’t pay for any more anesthesia.”
This did not float. It sank under a torrent of angry criticism this week and Anthem reversed its proposal.
We would hope that profiteering with abusive copays for obesity medicines will not fly, either. This emerging practice is dishonest and wrong.
Click here for reporting on this reprehensible behavior by health insurers. For perspective on the pressure for reform of PBMs, click here and here.
Saffron Farm Workers in Iran, photograph by Safa Daneshvar, licensed under CC BY-SA 3.0
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December 13, 2024
