The Battle Over What Meds I Should Take
While campaigning, President Trump promised to “knock out the middleman” referring to pharmacy benefit managers (PBMs). Please do Mr. President.
Those are the companies that run prescription plans for the insurers including Medicare. At this point, there probably isn’t one American who hasn’t run into a drug proscribed by their doctor that was denied by the PBM. Then comes the inevitable fight between you, your doctor, and the PBM over what you should be taking. Often the company will use the excuse that the medication is not in their formulary.
Over the years, my doctor and I have gone a couple of roundThe s with these behemoths and somehow managed to be accommodated. Many Americans who are receiving their insurance through work can’t exactly look for another plan for their needs. Many are stuck in an eternal battle with the only winners in this battle…the companies that own these PBMs.
In the United States, you often hear we have the most technological advanced care in the world. The world’s rich and elites come here to be treated for their illnesses. That is true because they can afford to buy that sophisticated treatment. They don’t worry about going bankrupt or whether their plans will pay for the needed treatment and medications.
I spent the first 25 years of my life being treated in the public health system for the most part. I was born in a New York City public hospital, and I went to their clinics for most needs including dental treatment as a kid. Then I spent the next 40 years either uninsured or through employer plans even when I owned the companies. As a company owner, I was always torn between the costs of the insurance and employees being able to have coverage.
When I turned 65, I received Medicare, and you don’t know how happy I am with that. I am happy with everything except the drug plan. For those of you who have not reached Medicare’s age, here is how it worked for me.
Every year during the open enrollment period, my wife and I would sit down at the government navigator website, enter my prescriptions, and see what drug plans are available in our area and how much the premium was.
This past December, only one of the nine plans that popped up had all my medications in their formulary. That didn’t mean that I wouldn’t have copays and deductibles, only that the drugs were covered under the plan. So, I signed up for that plan on December 5, 2024.
In January, the new plan year with my new PBM guarding my medications began, and the doctor sent in the prescriptions to be filled. All were accepted except the one for Metformin, a drug for Type 2 diabetes. It no longer is in their formulary. How can that be one month later?
Metformin first went on the market in 1957 in France and eventually was approved for use in the U.S. In 2022, it was the second most prescribed medications in the U.S. with more than 86 million prescriptions. It has worked well in managing my disease and is much cheaper than a Semaglutide such as
Ozempic. They are not covered by my plan either.
The three top pharmacy benefit managers are owned by CVS Health, Cigna, and United Health Group. They are hardly trying to do the best for employers, employees, clients, or patients. The PBMs sole mission is to keep costs down and their company owners’ profits up.
If Trump wants to do one thing for Americans and their healthcare, he needs to fight for patients to have the medicine their physicians say they need at an affordable cost. I am not looking for a free ride even with Medicare. My wife and I paid $750 a month in premiums in 2024 including our supplemental and prescription plans. Thankfully, we can afford to do so.
What about the people that can’t? They are left thrown to the medical industrial complex’s wolves. Like so much in our country today, medicine is top notch. If only 95% of Americans could afford it.