Kevin Pho: Hi, and welcome back to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Yemi Famuyiwa. She’s a fertility specialist and founder of the Montgomery Fertility Center. Today’s KevinMD article is “The Hidden Impact of Pharmacy Benefit Companies on Fertility Treatments.” Yemi, welcome back to the show.
Yemi Famuyiwa: Thank you. Thank you for having me.
Kevin Pho: So we’re going to talk today about pharmacy benefit companies and their impact on fertility treatments. Before talking about this article, what led you to write it in the first place?
Yemi Famuyiwa: Curiosity. Patients were always coming back to me trying to find out… I think it’s a whole smorgasbord of what’s going on with the pharmacy world, especially with patients. So, I wanted to delve into it a little bit, try to figure out what’s going on with pharmacy benefits, how patients are getting their medications, and how it’s influencing the pricing of what people are paying for their medication. That’s where the interest started.
Kevin Pho: All right. So, some definitions first before we go into your article. What exactly is a pharmacy benefit company?
Yemi Famuyiwa: Pharmacy benefit companies or pharmacy benefit managers—PBCs or PBMs—are organizations that were originally set up to help patients navigate between the patients and the formulary—the medications they get. They’re supposed to help patients get access to their medications faster, right? They intervene between insurance companies and the medications that patients get.
Kevin Pho: A middleman, if you will?
Yemi Famuyiwa: Sure.
Kevin Pho: And in your world of fertility treatments, what are common medications that involve pharmacy benefit companies?
Yemi Famuyiwa: The most common ones are the most expensive ones. Your gonadotropins, we call them—the injectables like Gonal-F, Menopur, and Follistim. Those are the key ones being regulated because they also happen to be the most expensive.
Kevin Pho: And just to give us some context, how many dollars are we talking about?
Yemi Famuyiwa: Oh, Lord have mercy. We’re talking thousands of dollars. Medication for one cycle of treatment could easily run four, five, six thousand dollars. So, we’re talking major bucks.
Kevin Pho: And tell me about your article. Tell me about how these pharmacy benefit companies are influencing the access to these drugs that your patients see.
Yemi Famuyiwa: One of the curiosities for me was peeling back the layers on these companies. What are they? What do they do? They’re supposed to negotiate prices for pharmacies from the companies that produce the medications—from the industrial makers. They also design the formulary that patients are allowed. They decide what medications go on the formulary that patients are allowed to get. They also process claims from pharmacy companies themselves. They process the claims and decide how much CVS or Rite Aid, for example, can charge. These companies decide that, and sometimes they run their own specialty pharmacy companies. The net effect of that is pricing can be in disarray, and the end result is that patients get a higher out-of-pocket portion.
Kevin Pho: So, give us some examples of this disarray. You mentioned that without insurance or any coverage, these medications can cost thousands of dollars. So, typically, what are the out-of-pocket costs that people are paying for these drugs when managed by a pharmacy benefit company?
Yemi Famuyiwa: They decide what medication goes on, and they decide what percentage of the medication cost is allocated to the patient. They make a profit as middlemen, so to increase that profit, they could simply allocate more of the cost to the patient. So, sometimes patients may end up with a higher out-of-pocket cost. Another thing is they decide where you buy the medication—whether you buy directly from them or from their network of pharmacies. Sometimes that’s not in the best interest of the patient. If the patient shops around, they may find that a local pharmacy down the road may provide the same medication for a lot less than the so-called network pharmacy. I always tell patients, if you get a bill of, say, six to eight thousand dollars, you might want to shop around a little on your own. You might find that even though the insurance says it covers your medication, your portion could be six thousand dollars. Should it really be six thousand? Not all of them are like that, but I think patients need to shop around and check when they get a high bill.
Kevin Pho: Another thing they don’t tell patients is sometimes the medication is allocated under medical benefit versus pharmacy benefit, right?
Yemi Famuyiwa: Right. So for patients, it’s a little confusing. You have to get your notebook out, write things down, take notes, and shop around to see what’s most beneficial for you.
Kevin Pho: On average, and I know you said a lot of prices were in disarray, what percentage of these expensive medicines do these benefit companies typically cover? Fifty percent, sixty percent? What’s typical?
Yemi Famuyiwa: It might be 50 percent or so, but sometimes it depends on what contract they negotiate with the insurance company itself. If they negotiate a lower percentage, then you’re lucky. If they don’t negotiate a better price, you’re out of luck.
Kevin Pho: And these companies sometimes dictate what treatment the patients get, correct? You mentioned step therapy earlier. Could you explain that?
Yemi Famuyiwa: Yes. They may enforce what’s called step therapy. For example, let’s say I have a patient who’s 40 or 41, whose ovarian reserve is dwindling. I may want to be aggressive and go directly to IVF. But the company may say, “No, we want you to do step therapy. Try IUI first, and if that doesn’t work, then you’ll do this and that.” All those steps delay treatment for patients. Sometimes I need to do what’s called a peer-to-peer. I’ll say, “Can I speak to your medical director? I need to explain why I’m doing this treatment so you understand the urgency.”
Kevin Pho: When you do peer-to-peer, how much time does that take, and how successful are you in overturning their decision?
Yemi Famuyiwa: I’m usually very successful because I can explain rationally why I’m using a particular medication at that time. But it does take time to get the medical director of the pharmacy benefit company on the line. I have to sit around, wait for them—it takes time to coordinate when I can talk to them. So, there’s a delay in care while going through these hurdles—one authorization after another. Sometimes authorizations can take up to a week or two. And once you get the authorization, you can’t necessarily start treatment right away because you have to wait for the patient’s menstrual cycle. Our treatments are cyclical. So I can’t just say, “Boom, I’m starting treatment.” I have to plan around the patient’s menstrual cycle. Then, in addition to that, I have to wait for the pharmacy benefit company and sometimes wait to coordinate speaking with their medical director. It’s a lot of administrative burden and a waste of time.
Kevin Pho: As a primary care physician, I know that with medications like blood pressure meds, insurance companies and pharmacy benefit companies may cover one thing but not another. From a prescriber’s standpoint, do these influence what you prescribe? Do you think about the patient’s pharmacy benefit company and what it will allow?
Yemi Famuyiwa: Sometimes it does. You may have to use a different medication or find something similar. It can definitely affect the medication choice and when I use it.
Kevin Pho: You also wrote that not all pharmacy benefit companies specialize in fertility medications. Some are more familiar with them than others, correct?
Yemi Famuyiwa: Right. You need a pharmacy that’s tailored to a fertility audience. If they’re not tailored to fertility, you find yourself teaching them, “I need to use this medication because this is the effect I’m looking for.” You tailor a patient’s therapy to fit them. For example, some patients respond better when you stimulate them as if they’re doing an IVF cycle, even if it’s just a medicated cycle for transferring embryos. You have to be careful to tailor the treatment for the patient. But the insurance company may say, “We want you to do this first, and we’re not going to approve treatment unless you do this.” So they have considerable control over the type of treatment you can offer.
Kevin Pho: Just to be clear, can patients change their pharmacy benefit manager, or is it dictated by their insurance plan?
Yemi Famuyiwa: For some insurance plans, it’s dictated. It’s not flexible. They might say, “This is the pharmacy you have to use, period. You can’t use anyone else.” If you don’t like it, you’re not getting the treatment. They can be very rigid with what treatment is allowed. There needs to be more advocacy for broader coverage so that patients and physicians aren’t held hostage. We need transparency. We need to know what’s happening behind closed doors. They need to tailor the formularies they design for fertility care, not just for primary care or dermatology. Can they give a broader range of medications so I don’t have to use the exact one they want if it doesn’t suit my patient?
