Why Health Insurance Reform Must Happen: Express Scripts Conspiring With Anthem Health to Rip Off Patients

Updated 2016-4-16: Anthem has sued Express Scripts for 3 billion dollars. This post contains hard evidence of Express Scripts culpability.

Updated 2012-3-16: see below

The conventional wisdom, as well as recent studies, say that having health insurance makes the cost of your prescription drugs lower. Recently, I have found the exact opposite to be true. In fact, having health insurance has made my prescription drug cost go up to 84% more than what I would pay without a prescription.

This seems to be the result of something going on between my health insurance provider Anthem Health, and the company they employ to service their prescriptions: Express Scripts. These companies seem to like to point the finger at Wallgreens for proposing higher prices.

I think there is something more sinister going on:  a cabal of for-profit health care corporations who are colluding to fraudulently overcharge consumers for their prescription drugs.

This prescription was not from Wallgreen’s, but a locally owned and operated pharmacy… On the top you can see what Express Scripts charges me:

And on the bottom you can see the price that the prescription costs with no insurance whatsoever. When I saw this, I was shocked.   The pharmacist who caught this (kudos to them) said that the additional cost would go to “help pay my deductible off sooner”.  As much as I’d like my high deductible to be met so my coverage actually starts getting me benefits, having my health insurance coverage almost double the cost of medication is in no way acceptable to me.

I made a stink about this on Twitter, and Anthem took notice of it and responded with the following letter a few days later:

Good afternoon Mr. Koren,
Your complaint regarding your prescription drug coverage through Express Scripts has been forwarded to me for research and a response.  Pharmacy pricing is determined by Anthem’s Pharmacy Benefit Manager Express Scripts Inc (ESI) and is not set by Anthem.  Our contracted rate that Anthem pays ESI for this prescription is $64.37.  There are many drugs in which a pharmacy’s cash price is cheaper than the contracted rate that we have with ESI and members certainly have the choice to pay the cheaper cash rate than what we have to pay to ESI.

Other examples of this are the drugs which are in pharmacies’ (such as Kings Soopers, Walmart, CVS) $4/10 generic programs.  We would not be able to refund the difference between our contracted rate and the cash price charged by the pharmacy.  You might want to contact the pharmacy to see if they would reverse the claim submitted and paid by us on 1/16/2012 and charge you the cash price and refund you the difference- it would be up to the pharmacy if they would be willing to do this for you. We cannot explain why a provider may charge a lower rate.  It is not uncommon for a provider to have a lower rate for cases of a patients financial hardship or limited ability to pay but we cannot comment on the reasons a provider may charge the lesser fee.

Julie Frisk
Senior Grievance & Appeals Analyst
Anthem Blue Cross and Blue Shield Colorado

Now this statement was supposedly “confidential”, and had the statement “Failure to maintain the confidentiality of e-mail and any attachment may subject you to penalties under applicable law.”, however since I signed no NDA, and because Anthem failed to publicly respond to this issue in a manner which they accept responsibility for their actions, I feel that is necessary to post this here in order to shine a light on what is happening.

Anthem points the blame to ESI for the prices…  But they were the ones that negotiated and eventually signed the contract that resulted in these rates.  Anthem health should not have signed such a contract, they should have, on behalf of their customers, politely told Express Scripts to go fuck themselves.  Instead, they signed on the dotted line.

When two huge companies can get together like this and squeeze likely billions of extra dollars out of the pockets of insured people who they are supposed to be saving money for, how can anybody make the argument that health insurance does not need to be reformed or regulated?

UPDATE 3-16

This afternoon my pharmacist called to inform me that Anthem/ExpressScripts says that if I have insurance, that I must pay the insured rate.  They said that if they gave me the lower rate, that they would have to give everybody else the lower retail rate.  Sounds fantastic to me!    But she said that they are making her collect the extra $29.37 from me, and that based on the federal law, they were mandated charge me the extra premium price that I pay to be insured. I gave her my card over the phone.

Even if I want to bypass my insurance and pay the lower retail rate, I’m apparently “forbidden” to do such a thing. Absolutely unbelievable.

Denver, Colorado, United States