Some Georgians say insurance companies forcing them to pay more for medications

ATLANTA — In a pandemic, getting access to your prescription medications can be a lifeline, but some Georgians claim their insurance companies are forcing them to pay higher prices to get medications at pharmacies owned by those insurers.

Last year, Georgia was one of the first states in the nation to outlaw the practice of so-called “pharmacy steering,” but advocates and patients told Channel 2′s Mike Petchenik the practice is still happening.

“What we were seeing was some of Georgia’s sickest patients were being steered from their provider of choice whether it be from a pharmacy or a physician where they’re getting these drugs, and they’re being steered to PBM (pharmacy benefits manager)- owned or PBM-affiliated pharmacies,” said Greg Reybold, general counsel for the Georgia Pharmacy Association. “What we see so often is patients receiving letters which basically say, ‘Effective such and such date you are going to be required to get these drugs at this pharmacy.’”

Pharmacist Jennifer Shannon led the charge to outlaw the practice after she opened her own pharmacy in Johns Creek.

“That patient steering has impacted so many people’s health outcomes in a negative manner,” said Shannon, owner of Lily’s Pharmacy. “I think people just do what they’re told because that’s what their benefits are designed for because it’s a closed, mandated way of receiving your medications. It’s never by choice.”

Shannon showed Petchenik examples of letters her patients have received telling them they need to change pharmacies and denial messages she’s received when trying to fill a prescription.

“Not only are they steering patients, but they’re steering the money into themselves,” she said.

Alan K, who asked Petchenik not to use his full last name, said he received such a letter over the summer after his employer changed insurance companies.

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“The letter basically said that I could get a 90-day supply … or if I didn’t want to do that, then I’d be paying full price for my prescriptions unless I made a phone call to them,” he said. “It really didn’t make much sense to me. I didn’t understand why I would be told I had to go to a certain pharmacy.”

Alan said he called his insurer to decline that change and later learned he would be saving money by keeping his prescription at Lily’s.

“There was no advantage to doing it,” he said.

In Georgia, the state insurance commissioner is tasked with investigating and policing allegations of steering.

Weston Burleson, a spokesperson for the office, told Petchenik they’ve received complaints about steering since the law took effect. He described the process in an email to Petchenik:

“'Steering' technically became illegal on January 1, 2020, but it wasn’t called ‘steering’ in the law until the bill this year,” said Burleson. “Additionally, the older law is pretty vague about what steering is, while the new law is much more specific. However, functionally, it became prohibited in 2020. We can fine PBMs, but that’s only if we find steering, and that steering was done after January 1, 2020. We’ve dug through the complaints we shared with you, and only a handful of the complaints appear to implicate behavior that looks like steering, and those mostly seem to be about insurers steering consumers, not PBMs. So for most of these, if we had the authority, we would reach out to the insurance company with the complaint and work towards a resolution on behalf of the consumer. But once we get our examination authority beginning July 1, we’ll be able to take a much closer look at PBMs and take action when necessary.”

Petchenik also received a statement from one of the largest pharmacies in the country, CVS, which owns insurer Aetna:

“The members served by our PBM in Georgia can go to any contracted pharmacy they choose, including independent pharmacies, which represent 40% of our pharmacy network in the state. They are not required to use CVS Pharmacy locations. The issue of so-called ‘steering’ is settled law in Georgia and we should instead focus on the root cause of high prescription drug costs: the prices set by manufacturers. We will continue to be part of the solution by working to reduce prescription drug costs and keep medications affordable for Georgians.”

A spokesperson for a Washington, D.C.-based trade group that represents the pharmacy benefits managers echoed this sentiment.

“People in Georgia are free to choose any pharmacy they want within a health plan’s network. That can be an independent pharmacy, that can be a supermarket pharmacy or that can be (a) chain pharmacy,” said Greg Lopes, assistant vice president for public affairs for the Pharmaceutical Care Management Association. “Consumers will choose pharmacies that meet their health care needs, that fit their budgets and that are convenient for them.”

Lopes said PBMs, who are hired by insurance companies to negotiate with drugmakers, are integral to keeping drug prices down. Lopes also said there are more independent pharmacies operating in Georgia now than there were 10 years ago.

“Drug manufacturers are going to continue to set high prices on their prescription drugs and raise prices on their prescription drugs,” he said. “The sole focus for pharmacy benefits managers and for pharmacies needs to be lowering prescription drug costs for consumers. It doesn’t need to be on profit.”

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