This is why i go to the last independent pharmacy in my town. They share space with the Ace Hardware store. They told me there used to be twelve in town! My friends say to me, “but they aren’t open on Sunday!” So what? Wallgreens closes for lunch everyday and they have closed two pharmacies in town recently. I never have to stand in a long line with the independent. As for mail order, the USPS said recently that the heat waves across the country is bad news for some drugs
Right when insurance companies start curing people's heart disease, cancer, and really bad athletes foot with their own pharmacies and pharmaceutical companies, the Gov decides to come in and bully the poor little guys.
"That Internet ophthalmologist who keeps making fun of us" 😂 They'd better not think of touching you, Dr. G! We'll send all our Jonathans against them!
Cigna is the only insurance I’ve had so far that refused to pay for a test that my in network cardiologist ordered because it “wasn’t medically necessary”. My heart rate was often abnormally high and the test was to check if my heart muscle was affected. The clinic just ate the charge so at least I didn’t have to fight about it.
@@Sashazur Checking whether there is cardiomyopathy, which can lead to heart failure and a drastic reduction in lifespan "is not medically necessary". Jesus fucking Christ.
Yeah, this was BCBS, but cut me off my asthma inhaler for 2 months because they'd "implemented step therapy" where you have to PROVE cheaper meds didn't work before allowing you to resume getting the meds that DO work. I told the woman on the phone, but YOU have the records! Right in your computer! I've had BCBS for 20 + years! I explained I started with over the counter.....went to rx this, the inhaler that, and now Albuterol. And voila!!!! "Oh yes, I see, it's right here, so we'll go ahead and approve that...." 😳👏🤦
Pharmacy student here, the independent that I worked at my first two years of school went bankrupt because of negative reimbursements. I still worry about how some of the patients are doing without the services chain pharmacies wouldnt bother to do.
I don't know your personal situation but here's my advice. Live like a pauper for as long as you can once you get out of school. Get a studio apartment in the bad part of town and a 15-20 year old car. Pay ahead as far as possible on your student loans. Switch retail jobs regularly and spend all your bonuses on paying that student debt down. The second your contract is up shop around for whoever will give you the biggest signing bonus. Do that multiple times even if you go back to old employers. Get therapy to end all your vices, whatever ones you have, no more hobbies until that debt is gone, no: alcohol, tobacco, nor any other substances, no guns, guitars, golfing, sporting events, no travelling, no eating out at restaurants or fast food, no gambling, take any and all shifts available including floating so long as you get OT compensation, no dating, no kids, no going out to movies, no more gaming subscriptions, no more streaming services, no more haircuts, no more shaving, no more new clothes, jump rope and do calisthenics at home, no gym memberships, no more coffee or tea, no to any type of junk food including soda, bottled water, chips, candy, just say no to everything that costs money. But always contribute the max amount to a 401k or 403c depending on what you're offered always max that out. Once those student loans are gone and you're square with those make sure you get that in writing a letter from the government or something on paper, through the mail that you're free and clear of them. Then never work in retail again. If you get a job with a hospital OR an insurance company, lab, research university whatever IMMEDIATELY start an MBA. Even if you take more loans to pay for it. I work at a local retail chain in Upstate NY and our company president is 32 years old and all he has on his resume is his Pharm.D, 3 years of work experience at a hospital, and an MBA. He's making at least $300,000k. If you don't like the thought of playing the game cut that line of thinking out right now. Everything is a Rich Man's game. If you're smart and want to do good in the world and you're capable you want to be somewhere where you make decisions. You don't want to have to follow lesser people's decisions for very long. If you're intelligent and have morals, ethics, values, and principles you need to be a decision-maker. I hope for the best for you.
@@FrauDoktorDoctora bit confused by what you mean. Are you saying that If a patient gets a service that costs 100, but the patient is on an insurance plan thay has a $200 copay or something, the provider that gave the service gets charged $100 by the insurance of the patient? Is that what a negative reimbursement means?
@@noblesseoblige319 Essentially, until quite recently, Pharmacy Benefits Managers (PBMs) have been able to impose various Direct And Indirect Remuneration (DIR) fees against claims after the fact, often times *months* after the patient has picked up the prescription and the pharmacy had received their payment. The payments on these medications are already quite small in most cases, sometimes actually costing the pharmacy money to fill when overhead costs or being forced to use a more expensive manufacturer get factored into the equation (because the PBM is generally the one that gets to determine how much is actually paid for a medication, regardless of what it actually costs the pharmacy to order it from their wholesaler). When a prescription claim would have negative reimbursement on the payment alone, the pharmacy at least has the option to refuse the claim, but these retroactive DIR fees made it so that a seemingly profitable claim would end up loosing the pharmacy money to fill instead of generating revenue. And PBMs abused the everloving hell out of this system, with usage of retroactive DIR fees increasing by over 100,000% between 2010 and 2020. Combined with various other anti-competitive practices, this resulted in unsustainably low revenue for many pharmacies, driving a lot of independent pharmacies out of business.
@@palimdragonmaster3k Please let me enjoy this retail price fantasy that the pharmaceutical industry absolutely would have pillaged from me in actual cash money dollars.
Cigna was my arch nemesis for 3 months when they wouldn't approve a procedure i needed until i made a formal complaint and spoke with several managers. Got the approval real quick after that.
Funny how something that would make you a Karen against most small to medium businesses turns into something entirely justified and actually laudable against the corpos... Well, it's probably the other way around, some legit complaint cases that worked against corpos that inspired the Karens to call for managers the moment they sense weakness in smaller businesses... Anyway, congratulation in getting what you were owed, but it's still a very weird concept for most of us not in the USA how you let private interests dictating who gets to live or die (or live the rest of their life in constant pain or crippled)...
My father and his sister did too! It's all because of these companies. "Ok, a 30-count bottle of Lipitor costs us $300. The insurance company says charge them a $10 copay." Later.. "They only gave us $20 for that bottle of Lipitor and told us to take it or leave it?" F**K
@@matthewgilfus1640 At some point, someone's going to have to contact Mark Cuban, and ask if he can expand CostPlus to wholesaling. He sells online, but of course, a) a whole lot of us want to talk to a pharmacist (drug interactions, side effects, etc.) and many a prescription is needed ... yesterday. He started CostPlus to save kids from this ripoff of jacked up prices, and just kept going, adding more drugs. I pay cash, starting at my new job, Cigna/CareMark forced either mailorder, or we don't cover it. Cash was easier, Walgreen's cheaper. The Mr's new insurance, Anthem Blue Cross/Blue Shield, paying cash is cheaper than his co-pay. ?!? Yes, cash, cheaper than co-pay. I'm guessing no-one's asking cash price.
Yep. Sadly my insurance company will only cover independent pharmacies if there are no "nearby" chains. But I have two chain pharmacies with a half mile so no chance.
@@waffles3629 Chain price made the Mr gasp, so they said they had a "special deal" coupon, and paid cash, which was cheaper than his co-pay using insurance. He filled it. I said check on CostPlus. The price was 50% of his "special deal" price, paying cash. CostPlus doesn't do insurance, and sells at 15% over cost. If nothing else, it'll give you an idea of just how bad we're being ripped off.
@AludraEltaninAltair they're the "middlemen" that tell your insurance what drugs to cover, except they also own your insurance and the pharmacy you go to in order to milk as much money from you, your employer, and drug manufacturers as humanly possible
@@Taxmt Left a few things out. PBMs now have access to our medical records, and contact our physicians to tell them we aren't taking the drugs they prescribed (when I pay cash, buy generic which they say they don't cover, far cheaper than using insurance). And, what tests they believe we should be having, annually. They're "helping", themselves.
Since Cigna Boss hadn't actually filed the lawsuit yet, I like to imagine Jimothy being like "Well, he said he wanted to sue and didn't stop me, sooooo....." and going ahead and filing it just like his boss asked him :3 (I imagine that during discovery, they are going to be VERY happy Jimothy is working there)
As a transplant survivor who Cigna has redirected through multiple “specialty” pharmacies they magically happen to own in order to get them to cover my life-sustaining medications, only to then still get charged shocking out-of-pocket costs well above my maximums, I can confirm. Honestly, they’ve been the most confusingly bad insurance provider I’ve ever had, and the bar wasn’t high - truly remarkable.
My hefty large employer has Cigna, and they treat us like a cash cow. I called the wrong Cigna number once, and got the crap service they give the smaller companies. Wow, wow wow wow.
@@032-m5x "Trump Derangement Syndrome" is funny to me because it sounds like Trump has made his supporters deranged. Which he absolutely has. It's what I think every time I see it. It's just funny the way you use it.
If Trump wins, I thing he will gut the FTC in the first 60 days. I mean, OF COURSE the government shouldn't stop evil companies from tricking their customers.
Oregon CPhT here. . . 10 years in Oregon, and over 75% of Medicaid claims are negative reimbursement. . . Keep bringing the people humor doc. We watch you for every upload.
Reminds me of a couple of recent high profile defamation cases in Australia. Both ended badly for the claimants, with the judge ruling ‘yeah, essentially, you did the bad things that they have been stating you did all along’
This is the health insurance my employer provides. They don’t pay crap and the only reason that I have had relatively “affordable” care is because I go through my hospital (employer) providers and pharmacy. I am still fighting over surgery to correct my deviated septum. Apparently, breathing correctly out of both nostrils is cosmetic.
Which is not only insane, but your septum is INSIDE YOUR NOSE where no one would see. I hope you can get sinus surgery at some point because its life changing. I got it two years ago, that shit is like a miracle. Medicaid paid for mine because I was super messed up, had to get my turbinates cut down because they were huge from chronic inflammation, plus fixing my deviated septum. Took MONTHS to get used to how much more oxygen I could breathe afterward.
My insurance company LITERALLY just sent me a letter saying they'll no longer cover the cost of my medication and I'll have to pay for it out of pocket if I continue to use another pharmacy. However, if I "choose" to use *their* pharmacy, they'll be happy to continue covering the cost of my medications🙃
My grocery store with in-house pharmacy is 7 minutes from my home. I still make a 35 minute drive to a independent pharmacy for every refill. I'm sick of the big pharmacy chains.
One friend who is a physician attended his medical school reunion Over half his classmates quit their medical careers because of their frustrations in their endeavors to care for their patients
@@khills the continuing corporization of medicine is a bane thought. I fully understand the headaches of independent practice, I've been running a practice for decades and I deal with insurance. Everything gets worse...
@@grilledflatbread4692 Sure, corporate practices are a huge problem - folks just have to look at what’s been going on with the Steward hospitals in MA for a good example of why they’re an awful idea. Personally, because I have both an autoimmune disorder and a rare chronic pain disorder, I get all my care thru an academic medical system, and I tend to recommend my friends to try to do similar if they can. Bonus: they’re their own massive thing, not owned by anyone, nor do they own anything but their system.
Sadly not surprised. I felt so bad for the poor insurance rep who had to tell me my claim for a lab sleep study was denied...because I did the home sleep study they told me I had to do to get the lab study covered. My retroactively denied claim *after* I'd done the lab study. Yep, they approved the lab study, I did the lab study, and they unapproved it. 17 months later, with two appeals and the help of an outside company that exists solely to get insurance to cover things, they finally reimbursed the money (because I'd been forced to pay the office if I wanted to remain a patient).
This one hits home. I’m on my 3rd pharmacy this year. First was a Walgreen that decided being my small town’s only pharmacy wasn’t profitable so they shut it down. Then I switched to a local owned pharmacy, which now also closed and sent all their prescriptions to the next closest Walgreens. Gonna try CVS next.
Ngl, as a tech who’s been around the block a few times now…..Wags may suck, but CVS is so. much. worse. Literally the bottom of barrel, and that’s a high bar to be bottom when hellgreens is in competition.
CVS' CareMark pharma branch is a ripoff, with many tactics. - "We don't carry nor cover the generic [for this outrageously expensive brand]." - They will sell you the prescription and not tell you same med/same brand/same dose now sits on the over the counter shelf, for 1/5th the cost. - They now have your prescription/Dr information, and will contact your doctor and steer your meds to their most profitable. Total dirtbags.
@@vikvavs55CVS techs have been like, consistently mean to me over the years and I guess that explains why. Poor morale is reflected back on the client and the employee at that point, it's pretty hard to blame them when their environment is making them miserable.
I discuss this with patients several times a week, as they transfer their rx to some mail order pharmacy with terrible customer service. Not to mention usually they need some rx still available locally, making it so that each med has to have a designated pharmacy. It generates excess work for my already understaffed rural practice. Also, want to stop an rx? Lol! Good luck, my pts get sent old scripts for years after stopping them. One of my little old ladies came in with over a thousand pills they sent her that she is not taking. Its dangerous as well as annoying.
I hear horror stories like this and am grateful my insurance is at least somewhat sensible. “You need to mail order!” “Go ahead and Google View my address and then tell me if you think that’s a good idea.” “Ooooooh, okay, no, we’ll just wave that and let you use the local pharmacy… please use ours, it’s cheaper!” “Well, the only one available to me is inside another business, and they refuse to carry any scheduled medicines. Since I take a few, wouldn’t it be safer for all of us if I filled all of my drugs at the same pharmacy?” “Absolutely! We’ll make sure you pay the same no matter where you fill!” Today, I spent almost an hour on the phone with insurance and one of their pharmacists, figuring out the medication options they cover after failing triptans. Being able to take that list to my doctor makes it faster for us all.
Same. I was once denied coverage for med A because I hadn't tried med B, so I had to try that first. Why hadn't I tried med B? Oh yeah, because they denied coverage because "it's not indicated for your condition" (it's ONLY indicated for my condition). So my doctor resubmitted for med B and...denied because it's not indicated for my condition. It was eventually solved by telling them to make up their minds (obviously a lot more complicated than that, but I'm not about to write an entire book in a UA-cam comment).
"We're gonna sue the feds!" Alright, you have my attention... "They said mean things about us" Now you certainly have my interest... "They investigated us and said we don't actually save people money and we're just a bunch of avaricious frauds!" Oh. Well, clearly you haven't been greasing the right palms. If you'd been cutting in the feds on your scheme, they wouldn't be saying means things about your avaricious fraud. "Shoot! You're right, what were we thinking?!" Or, maybe you could just not be avaricious frauds. "What was that? I was too lost in my dreams of obscene amounts of low-effort consequence-free money..."
Ah, Cigna… the guys who took a FULL YEAR to work through the appeal for my preferred stimulant, approved one dose, and then denied a dose increase one month later. They suck so much almost no providers outside of the major hospital networks in my area will take them and I had to switch up a bunch of my care when I had to switch to them unexpectedly. I’m off them now and couldn’t be happier to see the back of them. Honestly I didn’t think anyone could top Aetna for pure shittiness, but Cigna comes close. Yet again, I’ve never had the misfortune of being on United Healthcare so there’s that…
I laughed when I heard news reports Cigna’s suing. Note to myself was good luck with that ! Thinking of all of those claims they deny for so many sick people. I hope Cigna gets a counter suit against them !
Truth is a complete defense to a claim of defamation. But lack of solid Anti-SLAPP regulations on the Federal level can make that moot, cause an entity such as a PBO can ruin someone financially, even if they lose their suit in the end. Course, government is different, but just something important for any hypothetical internet ophthalmologists...
My little town had the best independent pharmacy until they closed a couple years ago. Cigna would only reimburse them to fill 30 days of a prescription. If I wanted my full 90 day allotment I would have to use Cigna’s ExpressScripts service. I loved the service and local pharmacists so I put up with the Cigna’s annoying policy. I blame Cigna’s anti-competitive practices for putting them out of business.
Oh, they own Express Scripts, *that* explains the problems I had with them... and the new problems. And their sudden new and strict changes to order quantities, order histories, payment tracking, refill functions.... Paper trails...
This is why Chair Khan of the FTC is one of my favorite people in government. Big businesses like Cigna hate her for actually cracking down on them and looking out for the little guy, so she's my fave.
I've worked in the pharmacy industry for a while, now, both on the PBM side and in a specialty pharmacy. Working on the PBM side was giving me migraines due to the level of stress and self-hatred I dealt with on a daily basis because I knew that my job actively impeded patient access to needed treatment. I only managed it for a few months. I cannot adequately express how much my mental health improved when I started working for the specialty pharmacy I work for, now. I'm so thrilled that there is going to be action taken against PBMs. Finally.
Good luck with that. In April I had to get 2 root canals, crowns to cover those teeth, a crown on another tooth, AND a filling. (Bad dental genetics caught up with me.) I hit my $1500 max in a heartbeat and paid around $5000 out of pocket.
Thank you soooo much. I use a small private Pharmacy that's been family-owned since 1975. I receive extremely good service and the ability to get medications that are NOT on the big chain Pharmacies' formulary! Better medication, NOT made in India or China, with better bioavailability and efficacy! Support private pharmacies, folks!
Ascension's PBM has called me twice, and been sent to voicemail twice, to inform me that my maintenance meds from my local pharm will now need to be ordered from them directly. Except I won't, and they can eat shit. I'll pick up sn extra shift every month if I have to so I can keep my local pharm's doors open.
Ask what the cash price is. The Mr just did so, and found out cash price is cheaper than his Anthem Blue Cross/Blue Shield insurance co-pay alone. How insane it that?!? I too pay cash. Generic at non-CVS pharmacy is a small fraction of what these price gouging "CVS CareMark" bills my Cigna insurance. Our Cigna used to send us rebate checks at end of year, due to the max 15% profit cap. Now Cigna's using CVS CareMark, to jack up expenses, to pocket the monies.
I hope it get more results. I was informed by Medicare that there will be a $2000 hard cap on out of pocket drug costs; insurance companies must provide their formularies and RX networks. You can now fully compare plans.
That _only_ means the price gouge stops hitting the Medicare recipients' wallet, and the greed gouge hits the total Medicare tab. Our corrupt government will not (do the same as other nations and) negotiate all the drug prices, for Medicare. And Medicaid.
I've had United Healthcare and Blue Cross. I gotta say, Cigna has been a massive improvement from those. But yeah, this pharmacy management stuff is BS.
Went to a CVS when I didnt have insurance to see how much it would cost to get up to date on my shots; for 6 vaccines, it would have cost me $1,500. The flu shot was $58, everything else was a minimum of $300. Sure, it would've been free with insurance, but just holy crap that's a lot of money for preventatives that would keep me from getting things like hepatitis or meningitis, two very awful diseases.
It's not free, with insurance. It comes out of your back pocket, in the form of insurance premiums. So, most don't shop around, because they don't know the total cost billed to insurance/your back pocket. CVS' CareMark furthers their financial interests, by telling customers they must go through their approved (jacked up price) providers.
Keep talking about this!!! This is what I want prospective representative’s and current representatives to address. The absolute injustice of our healthcare system and what a fucking racket insurance is among other issues that actually affect the majority of Americans.
I have Cigna. Every month or so they mail or call to try to get me to switch to their own mail order pharmacy. I keep telling them no, I’m happy with the one I already use that’s exactly the same prices.
"If you want to sue the governement for making it's job and showing the public your nauseous practices, you'll need a great lawyer. You'll nezed the eagle team!"
I love how CVS Caremark is my PBM, and I'm only allowed to fill scripts with CVS mail order and 1 fill at a local CVS. Except there are no CVS locations within an hour of me and it takes over two weeks to get any fills by mail. Filling at outside pharmacies costs an arm and a leg. Seems legit
I imagine this has to do with forcing patients to use express scripts or they won’t cover their meds? Or the $30+ billion in revenue they made last quarter? Or the fact that the specialty infusion nurse (me) are paid salary so they don’t have to pay overtime? I ended up quitting.
My faint glimmer of hope is that Timothy is still employed, meaning his boss probably actually genuinely is confused about all of this, and appreciates Timothy as a sanity check.
Brits going through same, "less [care] for more [money]", with "public [bilk]/private [profit] partnerships" in their healthcare. Cross pollination of Worst Practices, when Reagan/Thatcher paired off. First blowup was bank deregulation on housing markets, but has spread like a cancer through other parts of the economies.
Man, I really hope this small family business gets a leg up against big government
Just like big government to punch down at a small neighborhood pharmacy. The nerve 😂
@@LeahDizon-d4h Truly a shame 😥
This is why i go to the last independent pharmacy in my town. They share space with the Ace Hardware store. They told me there used to be twelve in town! My friends say to me, “but they aren’t open on Sunday!” So what? Wallgreens closes for lunch everyday and they have closed two pharmacies in town recently. I never have to stand in a long line with the independent. As for mail order, the USPS said recently that the heat waves across the country is bad news for some drugs
I wanna help, is there a Gofundme?
Right when insurance companies start curing people's heart disease, cancer, and really bad athletes foot with their own pharmacies and pharmaceutical companies, the Gov decides to come in and bully the poor little guys.
"That Internet ophthalmologist who keeps making fun of us" 😂
They'd better not think of touching you, Dr. G! We'll send all our Jonathans against them!
What an unstoppable and glorious force that would be!
😂😂😂😂😂
Mondays through Fridays from 9 am to 3 pm of course
SEND IN THE JOHNATHANS *ride of the rohirrim plays*
You have a Jonathan? How do I get one?
Oooooo, Cigna! The insurance company that claimed I didn't need an MRI for my daily post covid migraines because "you don't get headaches".
🤦
Cigna is the only insurance I’ve had so far that refused to pay for a test that my in network cardiologist ordered because it “wasn’t medically necessary”. My heart rate was often abnormally high and the test was to check if my heart muscle was affected. The clinic just ate the charge so at least I didn’t have to fight about it.
@@Sashazur Checking whether there is cardiomyopathy, which can lead to heart failure and a drastic reduction in lifespan "is not medically necessary". Jesus fucking Christ.
Yeah, this was BCBS, but cut me off my asthma inhaler for 2 months because they'd "implemented step therapy" where you have to PROVE cheaper meds didn't work before allowing you to resume getting the meds that DO work. I told the woman on the phone, but YOU have the records! Right in your computer! I've had BCBS for 20 + years! I explained I started with over the counter.....went to rx this, the inhaler that, and now Albuterol. And voila!!!! "Oh yes, I see, it's right here, so we'll go ahead and approve that...." 😳👏🤦
Ignorant person here-
Is it normal to get an mri for migraines?
You have no idea how wide my grin was when I saw the FTC was moving forward with its legal actions against PBMs
Pharmacy student here, the independent that I worked at my first two years of school went bankrupt because of negative reimbursements. I still worry about how some of the patients are doing without the services chain pharmacies wouldnt bother to do.
I don't know your personal situation but here's my advice. Live like a pauper for as long as you can once you get out of school. Get a studio apartment in the bad part of town and a 15-20 year old car. Pay ahead as far as possible on your student loans. Switch retail jobs regularly and spend all your bonuses on paying that student debt down. The second your contract is up shop around for whoever will give you the biggest signing bonus. Do that multiple times even if you go back to old employers. Get therapy to end all your vices, whatever ones you have, no more hobbies until that debt is gone, no: alcohol, tobacco, nor any other substances, no guns, guitars, golfing, sporting events, no travelling, no eating out at restaurants or fast food, no gambling, take any and all shifts available including floating so long as you get OT compensation, no dating, no kids, no going out to movies, no more gaming subscriptions, no more streaming services, no more haircuts, no more shaving, no more new clothes, jump rope and do calisthenics at home, no gym memberships, no more coffee or tea, no to any type of junk food including soda, bottled water, chips, candy, just say no to everything that costs money. But always contribute the max amount to a 401k or 403c depending on what you're offered always max that out.
Once those student loans are gone and you're square with those make sure you get that in writing a letter from the government or something on paper, through the mail that you're free and clear of them.
Then never work in retail again. If you get a job with a hospital OR an insurance company, lab, research university whatever IMMEDIATELY start an MBA. Even if you take more loans to pay for it. I work at a local retail chain in Upstate NY and our company president is 32 years old and all he has on his resume is his Pharm.D, 3 years of work experience at a hospital, and an MBA. He's making at least $300,000k. If you don't like the thought of playing the game cut that line of thinking out right now. Everything is a Rich Man's game.
If you're smart and want to do good in the world and you're capable you want to be somewhere where you make decisions. You don't want to have to follow lesser people's decisions for very long. If you're intelligent and have morals, ethics, values, and principles you need to be a decision-maker. I hope for the best for you.
How do you get a Negative Reimbursement‽
When they make you pay a penalty on the money you have to pay them back that they paid you because they decided you didn't do something right.
@@FrauDoktorDoctora bit confused by what you mean.
Are you saying that If a patient gets a service that costs 100, but the patient is on an insurance plan thay has a $200 copay or something, the provider that gave the service gets charged $100 by the insurance of the patient? Is that what a negative reimbursement means?
@@noblesseoblige319 Essentially, until quite recently, Pharmacy Benefits Managers (PBMs) have been able to impose various Direct And Indirect Remuneration (DIR) fees against claims after the fact, often times *months* after the patient has picked up the prescription and the pharmacy had received their payment. The payments on these medications are already quite small in most cases, sometimes actually costing the pharmacy money to fill when overhead costs or being forced to use a more expensive manufacturer get factored into the equation (because the PBM is generally the one that gets to determine how much is actually paid for a medication, regardless of what it actually costs the pharmacy to order it from their wholesaler).
When a prescription claim would have negative reimbursement on the payment alone, the pharmacy at least has the option to refuse the claim, but these retroactive DIR fees made it so that a seemingly profitable claim would end up loosing the pharmacy money to fill instead of generating revenue. And PBMs abused the everloving hell out of this system, with usage of retroactive DIR fees increasing by over 100,000% between 2010 and 2020.
Combined with various other anti-competitive practices, this resulted in unsustainably low revenue for many pharmacies, driving a lot of independent pharmacies out of business.
I am real proud of myself for costing cigna about $12,000 last month.
Woohoo!
While I strongly support sticking it to the insurance companies, I also wish you a speedy recovery from whatever it is.
I'm pretty sure that what they actually pay out is going to be fractions of that
@@palimdragonmaster3k Please let me enjoy this retail price fantasy that the pharmaceutical industry absolutely would have pillaged from me in actual cash money dollars.
Good work. Also, feel better.
How dare they say the quiet part out loud after letting us rake in profits for so long
Cigna was my arch nemesis for 3 months when they wouldn't approve a procedure i needed until i made a formal complaint and spoke with several managers. Got the approval real quick after that.
That's just typical healthcare insurance. They are designed to put barriers and only reward the diligent.
Funny how something that would make you a Karen against most small to medium businesses turns into something entirely justified and actually laudable against the corpos...
Well, it's probably the other way around, some legit complaint cases that worked against corpos that inspired the Karens to call for managers the moment they sense weakness in smaller businesses...
Anyway, congratulation in getting what you were owed, but it's still a very weird concept for most of us not in the USA how you let private interests dictating who gets to live or die (or live the rest of their life in constant pain or crippled)...
@@raznaakWe don't make that decision. Our "democracy" decides for us.
@@raznaak You need to get out more often.
Who do you complain to?
Sir, my parents ran an independent pharmacy (remember those?) for something like 40 years. Always great, but I'm feeling this one. Thx.
My father and his sister did too! It's all because of these companies. "Ok, a 30-count bottle of Lipitor costs us $300. The insurance company says charge them a $10 copay." Later.. "They only gave us $20 for that bottle of Lipitor and told us to take it or leave it?" F**K
@@matthewgilfus1640 At some point, someone's going to have to contact Mark Cuban, and ask if he can expand CostPlus to wholesaling. He sells online, but of course, a) a whole lot of us want to talk to a pharmacist (drug interactions, side effects, etc.) and many a prescription is needed ... yesterday.
He started CostPlus to save kids from this ripoff of jacked up prices, and just kept going, adding more drugs.
I pay cash, starting at my new job, Cigna/CareMark forced either mailorder, or we don't cover it. Cash was easier, Walgreen's cheaper.
The Mr's new insurance, Anthem Blue Cross/Blue Shield, paying cash is cheaper than his co-pay. ?!? Yes, cash, cheaper than co-pay. I'm guessing no-one's asking cash price.
Yep. Sadly my insurance company will only cover independent pharmacies if there are no "nearby" chains. But I have two chain pharmacies with a half mile so no chance.
@@waffles3629 Chain price made the Mr gasp, so they said they had a "special deal" coupon, and paid cash, which was cheaper than his co-pay using insurance. He filled it. I said check on CostPlus. The price was 50% of his "special deal" price, paying cash.
CostPlus doesn't do insurance, and sells at 15% over cost.
If nothing else, it'll give you an idea of just how bad we're being ripped off.
When I first learned about PBMs I couldn't believe it was legal.
Good work, Dr. G.💌
What are PBMs?
@AludraEltaninAltair they're the "middlemen" that tell your insurance what drugs to cover, except they also own your insurance and the pharmacy you go to in order to milk as much money from you, your employer, and drug manufacturers as humanly possible
@@AludraEltaninAltairPharmacy benefit manager
@AludraEltaninAltair: Pharmacy Benefits Manager
@@Taxmt Left a few things out.
PBMs now have access to our medical records, and contact our physicians to tell them we aren't taking the drugs they prescribed (when I pay cash, buy generic which they say they don't cover, far cheaper than using insurance). And, what tests they believe we should be having, annually. They're "helping", themselves.
Hey Cigna
We knew
-The Public
Since Cigna Boss hadn't actually filed the lawsuit yet, I like to imagine Jimothy being like "Well, he said he wanted to sue and didn't stop me, sooooo....." and going ahead and filing it just like his boss asked him :3
(I imagine that during discovery, they are going to be VERY happy Jimothy is working there)
From an 11 year pharmacy veteran, thank you!@
The long-suffering Jimothy. 😢
May not be suffering much longer. Discovery is gonna be VERY happy Jimothy works there.
Brother of both Himothy and Bimothy. Those triplets do not get the credit they deserve. 😢
As a transplant survivor who Cigna has redirected through multiple “specialty” pharmacies they magically happen to own in order to get them to cover my life-sustaining medications, only to then still get charged shocking out-of-pocket costs well above my maximums, I can confirm. Honestly, they’ve been the most confusingly bad insurance provider I’ve ever had, and the bar wasn’t high - truly remarkable.
Paid Cigna a bunch of money for years while barely using it, then when I needed them I couldn't get any help at all. What a racket!
My hefty large employer has Cigna, and they treat us like a cash cow. I called the wrong Cigna number once, and got the crap service they give the smaller companies. Wow, wow wow wow.
This is also reminding me of JD Vance saying "the rules were that you weren't going to be fact-checking."
🤣
You mean we're not allowed to lie on a televised national debate?!
@@032-m5x "Trump Derangement Syndrome" is funny to me because it sounds like Trump has made his supporters deranged. Which he absolutely has. It's what I think every time I see it. It's just funny the way you use it.
@@032-m5x Awww, did the poow wittle Twumpanzee get twiggered?
If Trump wins, I thing he will gut the FTC in the first 60 days.
I mean, OF COURSE the government shouldn't stop evil companies from tricking their customers.
Oregon CPhT here. . . 10 years in Oregon, and over 75% of Medicaid claims are negative reimbursement. . . Keep bringing the people humor doc. We watch you for every upload.
Man. OHP will dictate what I can take and where I can get my meds, and then ALSO not pay you guys at all? That's garbage.
I thought you were going to bring up the Streisand effect but then you mentioned discovery - even better.
Ah are they practicing medicine without a license? Maybe someone should prosecute that!
Reminds me of a couple of recent high profile defamation cases in Australia. Both ended badly for the claimants, with the judge ruling ‘yeah, essentially, you did the bad things that they have been stating you did all along’
Discovery is such a powerful tool! My law and medicine loves are combining in this video in a beautiful way!
They should have stuck with suing the ophthalmologist. I hear he's funny and I see he has tens of dollars.
“Tens of dollars”. 😂
This is the health insurance my employer provides. They don’t pay crap and the only reason that I have had relatively “affordable” care is because I go through my hospital (employer) providers and pharmacy. I am still fighting over surgery to correct my deviated septum. Apparently, breathing correctly out of both nostrils is cosmetic.
Which is not only insane, but your septum is INSIDE YOUR NOSE where no one would see. I hope you can get sinus surgery at some point because its life changing. I got it two years ago, that shit is like a miracle. Medicaid paid for mine because I was super messed up, had to get my turbinates cut down because they were huge from chronic inflammation, plus fixing my deviated septum. Took MONTHS to get used to how much more oxygen I could breathe afterward.
Sounds like a 💩 employer if you can’t get good insurance. Companies try to cut costs when it comes to insurance. Wish he did a video on that.
My insurance company LITERALLY just sent me a letter saying they'll no longer cover the cost of my medication and I'll have to pay for it out of pocket if I continue to use another pharmacy. However, if I "choose" to use *their* pharmacy, they'll be happy to continue covering the cost of my medications🙃
Get those documents together and send em to the FTC.
Yes, CareMark covers 3 months at local pharmacy only. Then their mailorder or nothing.
Can we class action lawsuit these assholes?
Thank you. Thank you a million times over.
My grocery store with in-house pharmacy is 7 minutes from my home. I still make a 35 minute drive to a independent pharmacy for every refill. I'm sick of the big pharmacy chains.
One friend who is a physician attended his medical school reunion
Over half his classmates quit their medical careers because of their frustrations in their endeavors to care for their patients
Yup. One of the reasons my relative who is a physician works for a hospital: let THEM fight with insurance, PBMs, etc.
@@khills And my aunt is a doctor for the VA. None of this "in network" crap, if a patient gets in front of her she can treat.
@@khills the continuing corporization of medicine is a bane thought. I fully understand the headaches of independent practice, I've been running a practice for decades and I deal with insurance. Everything gets worse...
@@grilledflatbread4692 Sure, corporate practices are a huge problem - folks just have to look at what’s been going on with the Steward hospitals in MA for a good example of why they’re an awful idea. Personally, because I have both an autoimmune disorder and a rare chronic pain disorder, I get all my care thru an academic medical system, and I tend to recommend my friends to try to do similar if they can. Bonus: they’re their own massive thing, not owned by anyone, nor do they own anything but their system.
An ex had to quit a WFH job with Cigna because having to inform so many people of denials, was causing her daily breakdowns.
Friend working for Kaiser said his job was to deny coverage until threatened with a lawyer.
Sadly not surprised. I felt so bad for the poor insurance rep who had to tell me my claim for a lab sleep study was denied...because I did the home sleep study they told me I had to do to get the lab study covered. My retroactively denied claim *after* I'd done the lab study. Yep, they approved the lab study, I did the lab study, and they unapproved it. 17 months later, with two appeals and the help of an outside company that exists solely to get insurance to cover things, they finally reimbursed the money (because I'd been forced to pay the office if I wanted to remain a patient).
Discovery: (in corner, wearing bondage gear) "KNEEL!"
Pharmacy Tech here. We don’t think about how our decisions will affect people. The truth shall set you free. 🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸🇺🇸
This one hits home. I’m on my 3rd pharmacy this year. First was a Walgreen that decided being my small town’s only pharmacy wasn’t profitable so they shut it down. Then I switched to a local owned pharmacy, which now also closed and sent all their prescriptions to the next closest Walgreens. Gonna try CVS next.
Please for the love of God do yourself a favor and avoid CVS like the plague.
Ngl, as a tech who’s been around the block a few times now…..Wags may suck, but CVS is so. much. worse. Literally the bottom of barrel, and that’s a high bar to be bottom when hellgreens is in competition.
CVS is restructuring. Just a heads-up.
CVS' CareMark pharma branch is a ripoff, with many tactics.
- "We don't carry nor cover the generic [for this outrageously expensive brand]."
- They will sell you the prescription and not tell you same med/same brand/same dose now sits on the over the counter shelf, for 1/5th the cost.
- They now have your prescription/Dr information, and will contact your doctor and steer your meds to their most profitable.
Total dirtbags.
@@vikvavs55CVS techs have been like, consistently mean to me over the years and I guess that explains why. Poor morale is reflected back on the client and the employee at that point, it's pretty hard to blame them when their environment is making them miserable.
I discuss this with patients several times a week, as they transfer their rx to some mail order pharmacy with terrible customer service. Not to mention usually they need some rx still available locally, making it so that each med has to have a designated pharmacy. It generates excess work for my already understaffed rural practice. Also, want to stop an rx? Lol! Good luck, my pts get sent old scripts for years after stopping them. One of my little old ladies came in with over a thousand pills they sent her that she is not taking. Its dangerous as well as annoying.
I hear horror stories like this and am grateful my insurance is at least somewhat sensible. “You need to mail order!”
“Go ahead and Google View my address and then tell me if you think that’s a good idea.”
“Ooooooh, okay, no, we’ll just wave that and let you use the local pharmacy… please use ours, it’s cheaper!”
“Well, the only one available to me is inside another business, and they refuse to carry any scheduled medicines. Since I take a few, wouldn’t it be safer for all of us if I filled all of my drugs at the same pharmacy?”
“Absolutely! We’ll make sure you pay the same no matter where you fill!”
Today, I spent almost an hour on the phone with insurance and one of their pharmacists, figuring out the medication options they cover after failing triptans. Being able to take that list to my doctor makes it faster for us all.
Does that include CostPlus? They aren't owned by a pharmacy benefit manager.
Stopping the Rx, in that case, is contacting the bank card and killing the auto-pay.
As someone who just got denied infusion therapy, after appealing it, on the basis of it being "medically unnecessary" I feel this.
Same. I was once denied coverage for med A because I hadn't tried med B, so I had to try that first. Why hadn't I tried med B? Oh yeah, because they denied coverage because "it's not indicated for your condition" (it's ONLY indicated for my condition). So my doctor resubmitted for med B and...denied because it's not indicated for my condition. It was eventually solved by telling them to make up their minds (obviously a lot more complicated than that, but I'm not about to write an entire book in a UA-cam comment).
"We're gonna sue the feds!"
Alright, you have my attention...
"They said mean things about us"
Now you certainly have my interest...
"They investigated us and said we don't actually save people money and we're just a bunch of avaricious frauds!"
Oh. Well, clearly you haven't been greasing the right palms. If you'd been cutting in the feds on your scheme, they wouldn't be saying means things about your avaricious fraud.
"Shoot! You're right, what were we thinking?!"
Or, maybe you could just not be avaricious frauds.
"What was that? I was too lost in my dreams of obscene amounts of low-effort consequence-free money..."
Ah, Cigna… the guys who took a FULL YEAR to work through the appeal for my preferred stimulant, approved one dose, and then denied a dose increase one month later. They suck so much almost no providers outside of the major hospital networks in my area will take them and I had to switch up a bunch of my care when I had to switch to them unexpectedly. I’m off them now and couldn’t be happier to see the back of them. Honestly I didn’t think anyone could top Aetna for pure shittiness, but Cigna comes close. Yet again, I’ve never had the misfortune of being on United Healthcare so there’s that…
Anthem Blue Cross/Blue Shield. Paying cash, is cheaper than their prescription co-pay.
The internet ophthalmologist part thoughhh xD
I feel Jimothy's time in the company is running short.
The CEO discovery is a thing is perfect.
I didn’t know the government was complaining about Cigna. My own complaining was too loud.
I laughed when I heard news reports Cigna’s suing. Note to myself was good luck with that ! Thinking of all of those claims they deny for so many sick people. I hope Cigna gets a counter suit against them !
I love how Lina Khan's FTC isn't holding back against ANYONE. If you fuck over consumers, they're coming for you
Always brilliant. Love these videos.
Truth is a complete defense to a claim of defamation. But lack of solid Anti-SLAPP regulations on the Federal level can make that moot, cause an entity such as a PBO can ruin someone financially, even if they lose their suit in the end. Course, government is different, but just something important for any hypothetical internet ophthalmologists...
There are rules about suing the federal government. Sovereign immunity is going to come into play.
This is true for average everyday targets for SLAPP suits, but the Federal Government itself has very deep pockets
The real reason they're doing this is to promote anti-FTC rhetoric that they're hoping some policymaker latches on to.
Your videos about insurance companies are my fav!!!
Deadpool would be proutld of this 4th wall break!
So excited my company is moving to Cigna for health insurance next year. *sigh*
Dang Jimmothy !!! What'd ya TELL him for ???? 🤨
Drug Dealers don't like other Drug Dealers?! Shocking!
Thank goodness for Jimothy!
Oh, do Caremark next (said the pharmacist 😂)
This video is about CareMark.
My little town had the best independent pharmacy until they closed a couple years ago. Cigna would only reimburse them to fill 30 days of a prescription. If I wanted my full 90 day allotment I would have to use Cigna’s ExpressScripts service. I loved the service and local pharmacists so I put up with the Cigna’s annoying policy. I blame Cigna’s anti-competitive practices for putting them out of business.
Spot on, hence the FTC investigation.
Oh, they own Express Scripts, *that* explains the problems I had with them... and the new problems. And their sudden new and strict changes to order quantities, order histories, payment tracking, refill functions.... Paper trails...
Just wait till they start on you and your doctor(s), with their new "Wellness Team". They're "helping".
This is why Chair Khan of the FTC is one of my favorite people in government. Big businesses like Cigna hate her for actually cracking down on them and looking out for the little guy, so she's my fave.
Small-time internet opthalmologists have had it good for TOO LONG >:[
PREACH THIS MESSAGE!!!
GO JIMOTHY YOU TELL HIM! Finally a round for Jimothy.
I've worked in the pharmacy industry for a while, now, both on the PBM side and in a specialty pharmacy. Working on the PBM side was giving me migraines due to the level of stress and self-hatred I dealt with on a daily basis because I knew that my job actively impeded patient access to needed treatment. I only managed it for a few months. I cannot adequately express how much my mental health improved when I started working for the specialty pharmacy I work for, now. I'm so thrilled that there is going to be action taken against PBMs. Finally.
Here I am, ready to start finding a new healthcare plan for 2025. A root canal hurts less (and if I’m fortunate, it’s covered insurance!) 🤣🤣🤣🤣🤣
Good luck with that. In April I had to get 2 root canals, crowns to cover those teeth, a crown on another tooth, AND a filling. (Bad dental genetics caught up with me.) I hit my $1500 max in a heartbeat and paid around $5000 out of pocket.
Thank you soooo much. I use a small private Pharmacy that's been family-owned since 1975. I receive extremely good service and the ability to get medications that are NOT on the big chain Pharmacies' formulary! Better medication, NOT made in India or China, with better bioavailability and efficacy! Support private pharmacies, folks!
I sure hope they don't sue that internet guy who makes fun of them, he sounds alright.
me, insured by Cigna: 👀👀
Crossover with legal eagle in universe?!?!
God I wish my health insurance wasn't fucking Cigna. My employer changed to Cigna from BPA last year and it's been a non-stop nightmare since 😢
Ascension's PBM has called me twice, and been sent to voicemail twice, to inform me that my maintenance meds from my local pharm will now need to be ordered from them directly.
Except I won't, and they can eat shit. I'll pick up sn extra shift every month if I have to so I can keep my local pharm's doors open.
Ask what the cash price is. The Mr just did so, and found out cash price is cheaper than his Anthem Blue Cross/Blue Shield insurance co-pay alone. How insane it that?!?
I too pay cash. Generic at non-CVS pharmacy is a small fraction of what these price gouging "CVS CareMark" bills my Cigna insurance. Our Cigna used to send us rebate checks at end of year, due to the max 15% profit cap. Now Cigna's using CVS CareMark, to jack up expenses, to pocket the monies.
I hope it get more results. I was informed by Medicare that there will be a $2000 hard cap on out of pocket drug costs; insurance companies must provide their formularies and RX networks. You can now fully compare plans.
That _only_ means the price gouge stops hitting the Medicare recipients' wallet, and the greed gouge hits the total Medicare tab.
Our corrupt government will not (do the same as other nations and) negotiate all the drug prices, for Medicare. And Medicaid.
As someone who survived a ruptured aorta and now has optic nerve damage. Being a super eye Dr, do you know of any progression in Optic nerve repairs?
🤩 wow. It’s getting real up in here. 😂
"You know what happens when you sue somebody, right?" That sounds foreboding.🤣
Oh no, what is my health insurance doing this time?
Oh is this why my dental insurance doubled!?
I've had United Healthcare and Blue Cross. I gotta say, Cigna has been a massive improvement from those.
But yeah, this pharmacy management stuff is BS.
It's funny because I had them but switched to Anthem because I got a new job and Anthem suuuucks.
@@nancydrewfan7890 The Mr just discovered paying cash is cheaper than Anthem's co-pay alone, at the pharmacy.
Yah Blue Cross sucks ass, but at least you can find their claims for the most part. Cigna patients don't exist in their own system. 🫤
Strange how people who do morally questionable things always seem to confuse "true" with "mean".
Went to a CVS when I didnt have insurance to see how much it would cost to get up to date on my shots; for 6 vaccines, it would have cost me $1,500. The flu shot was $58, everything else was a minimum of $300. Sure, it would've been free with insurance, but just holy crap that's a lot of money for preventatives that would keep me from getting things like hepatitis or meningitis, two very awful diseases.
It's not free, with insurance. It comes out of your back pocket, in the form of insurance premiums.
So, most don't shop around, because they don't know the total cost billed to insurance/your back pocket.
CVS' CareMark furthers their financial interests, by telling customers they must go through their approved (jacked up price) providers.
Keep talking about this!!! This is what I want prospective representative’s and current representatives to address. The absolute injustice of our healthcare system and what a fucking racket insurance is among other issues that actually affect the majority of Americans.
Write them. You, write your representatives. Raise the noise level.
I have Cigna. Every month or so they mail or call to try to get me to switch to their own mail order pharmacy. I keep telling them no, I’m happy with the one I already use that’s exactly the same prices.
I'm the on call fan again.
This is CVS with Caremark. It’s way cheaper to fill stuff at CVS.
It's way cheaper to buy generic, from Walgreen's, paying cash.
Don't worry Cigna, people have short memory and have forgot this just in time for the executive christmas bonuses.
"If you want to sue the governement for making it's job and showing the public your nauseous practices, you'll need a great lawyer.
You'll nezed the eagle team!"
Jimothy doesn’t seem too worried.
There’s also the Streisand Effect. Many people he no idea about any of this until Cigna decided to get angry
I love how CVS Caremark is my PBM, and I'm only allowed to fill scripts with CVS mail order and 1 fill at a local CVS. Except there are no CVS locations within an hour of me and it takes over two weeks to get any fills by mail. Filling at outside pharmacies costs an arm and a leg. Seems legit
1) Ask cash price at non-CVS pharmacy.
2) Look up the price at (online) CostPlus.
Let's all hope that last line comes true.
Truly a beautiful video!
Yeah I am not holding my breath on the govt holding them accountable. I doubt anything actually happens to benefit the little guy.
Did you..did you print the money? 😂
I imagine this has to do with forcing patients to use express scripts or they won’t cover their meds? Or the $30+ billion in revenue they made last quarter? Or the fact that the specialty infusion nurse (me) are paid salary so they don’t have to pay overtime? I ended up quitting.
Lol. This is actually a real thing that's happening right now
Where’s our favorite people on here needing some humor right now ❤ it’s a little stressful in Florida right now
Now we just need a crossover between this Jimothy and the Jimothy that works for the Devil on TheChirsBarnett’s channel
That is defamatory of yout Dr. G!
I kinda want to see him get arrested.
laughs in Pharmacist
I'm sure the tears are real
WOO HOO LINA KHAN! ❤❤❤ You go girl! Harris better keep her on! Just think what would happen if Lina Khan and Katie Porter worked together! 😍😍
My faint glimmer of hope is that Timothy is still employed, meaning his boss probably actually genuinely is confused about all of this, and appreciates Timothy as a sanity check.
Worked in healthcare for several decades. Cigna coverage was/is the worst. Humana not far behind.
I got a deal on Cigna insurance with my emergency medicine membership. Maybe the deal they really got is me.......
Please make a video next about how Providence is dissolving or something? Weird things are happening with it, in Oregon anyway
Not an American here but already feel bad about you Americans.
Brits going through same, "less [care] for more [money]", with "public [bilk]/private [profit] partnerships" in their healthcare.
Cross pollination of Worst Practices, when Reagan/Thatcher paired off. First blowup was bank deregulation on housing markets, but has spread like a cancer through other parts of the economies.