ST. LOUIS COUNTY — About 70 pharmacists and advocates gathered outside Express Scripts’ North County headquarters Friday, voicing wide-ranging complaints about the company and its peers in the business of drug-industry middlemen.
Pharmacists and activists accused the company — and competitors like Optum Rx and CVS Caremark — of pushing independent pharmacies into unfavorable, “take-it-or-leave-it” contracts, and pressuring patients to switch to mail-order prescriptions.
“One of the most trusted health care professions, and they’re driving us out of business,” said Michelle Dyer, who owns a long-term care pharmacy in Illinois.
Pharmacy benefits managers, or PBMs, like Express Scripts, occupy the space between drug manufacturers, pharmacies and insurers. They negotiate rebates and fees, create drug formularies and reimburse for prescriptions. The industry has become a target for lawmakers and regulators in recent years over concerns about opaque pricing practices and tie-ups with large insurers.
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Express Scripts is part of Evernorth Health Services, which is owned by Cigna.
Dyer said that last year she closed three pharmacies she owned in rural Illinois towns: Carlinville, Gillespie and Bunker Hill. She blamed what she described as “predatory, noncompetitive contracts” with PBMs.
Now she operates just a small portion of the remaining business, filling prescriptions for nursing homes and assisted living facilities.
David Bagot said he has had to cut staff at the rural, independent pharmacy he owns in Petersburg, Illinois due to the payment structure of these contracts. Bryan Kiefer, who owns three pharmacies in southeast Missouri, said he loses $60 to $70 on some prescriptions.
Owen Sullivan, who owns seven locations in Central Illinois, said he has cut his hours. He’s doing more business than he can handle — and there’s no benefit to bringing in any more, he said, because it’s just not profitable.
Faced with such complaints in the past, the industry has generally held that the pharmaceutical companies set the prices for drugs, and PBMs exist to lower costs.
Express Scripts said in a statement Friday that the company works “relentlessly” to lower costs for patients and offer access to medications in the way that is most convenient for them. More than 90% of its prescriptions are filled at retail pharmacies.
Last year Express Scripts announced a slew of actions to improve transparency and cap patients’ out-of-pocket drug costs. Those included a program to show members what Express Scripts pays pharmacies for prescriptions and other details, and new financial disclosures to the Securities and Exchange Commission. The company also announced a program designed to increase reimbursements for independent, rural pharmacies.
The Friday event was organized by Unite for Safe Medications and Pharmacists United for Truth and Transparency. Representatives were in attendance from the National Community Pharmacists Association, the American Pharmacists Association, and the AIDS Healthcare Foundation (which runs pharmacies in 17 states, with one in Chicago and none in Missouri).
Lucas Kunce, a Democrat campaigning to unseat U.S. Senator Josh Hawley in November, joined the protesters and called for federal lawmakers and regulators to take antitrust action against PBMs.
Kunce complained that in 2022 Express Scripts dropped about 15,000 independent pharmacies from its TRICARE network, the health care program for members of the military, which Kunce said his family uses.
Loretta Boesing, founder of Unite for Safe Medications, said she was surprised by the turnout. It was the first protest she had organized. An insurance consultant from Park Hills, Boesing founded her organization after years of frustration with the specialty medications her son, Wesley, relies on.
Boesing said Wesley received a liver transplant as a 2-year-old after a severe case of influenza. He now relies on medications that he takes every 12 hours.
The family tried to fill the prescriptions at Walgreens, but was told that the specialty medications couldn’t be filled there. For a time they received the medications from the pharmacy at SSM Health Cardinal Glennon Children’s Hospital, but eventually it, too, notified the family that they couldn’t receive the specialty drugs there. The family was forced to switch to mail-order deliveries of the prescriptions, overseen, over the years, by two different PBMs.
But Boesing wasn’t comfortable with that. Her son’s medications must be kept at room temperature. Even when they were shipped with ice packs, she worried about them overheating in the back of the delivery trucks in the middle of the Missouri summer. She remembers asking a UPS driver about the temperature in the back of his truck, and he said it was so hot it was hard to breathe.
The family has found a solution for Wesley, who is now 14 years old: They switched from employer-sponsored health insurance to a marketplace plan that allows them to fill the prescriptions at a pharmacy.
But Boesing worries that one day that option, too, will disappear.