Apparently, my health insurer Aetna, which is actually not an "insurer" at all but a TPA, is changing PBMs from Express Scripts to CVS Caremark.
To decode that last sentence and its significance:
A "TPA" is a third-party administrator of the health benefits that are being provided by a large company which is actually "self-insured." When you are dealing with health benefits you need to understand who is actually providing them because you need to understand the rules that govern them and the pressure points if you need to complain when things go awry. For example, generally speaking, a self-insured plan isn't going to fall under the jurisdiction of the Commissioner of Insurance for your state, so cc'ing them on a Stiff Note is really not much of an implied threat. Self-insured plans fall under the loving care of the feds, in particular the Department of Labor and the Internal Revenue Service, but they tend not to be that consumer-oriented. Also, they're really busy.
A PBM is a "pharmacy benefits manager." This is a subset of TPAs in charge of arranging for payment (or not) of medications and (some types of sort-of DME, see digression below) prescribed by the clinicians who are paid for by the benefits administered by another TPA. Because that is more efficient (it actually may be, for all I know. Pardon my momentary cynicism).
The PBM switch has apparently been in the works for a while, and I am pretty sure that
the transition was contemplated to occur in 2017 (like, January 2017).
The hotlink on Aetna's website to the press release announcing its "strategic alliance" is, of course, broken (when I pointed this out to the Health Advocate she actually snorted).
The "Q and A for Aetna Members" says "we will keep your employer informed."
The employer (of the consort of the Dark Goddess) knows nothing of when or how the PBM transition will be implemented. For all I know the deal fell through or was blocked by the Justice Department on antitrust grounds.
Our family is strong-armed into ordering a great deal of our medication (and certain types of sort-of DME, see digression below) through a PBM or
face stiff financial penalties for the "luxury" of using a retail
pharmacy. I have no information about how our scripts currently residing at Express Scripts currently eligible for
refill will or will not be transferred to CVS Caremark, and when. Maybe it will be seamless. I should note that historically there has been considerable lag time between the time when we mail our prescriptions from Washington state to the processing center, which always seems to be in Florida, and the time the prescriptions are shipped from some other far-flung part of the country. When I can coax a clinician into e-prescribing, that reduces the transit time of one leg, but only one leg, of the journey.
My promised digression: one of the great oddities of my current PBM is that, if you get a "prescription" for medication that is available over-the-counter (for example, low-dose aspirin), the PBM will provide it essentially free (because this sort of preventive medication is regarded as a good investment in your health). Also, there are certain types of "durable medical equipment," or DME, also available over-the-counter, but that if "prescribed" are also provided more cheaply than if just purchased at the store. The oddity goes up to eleven when you realize that DME includes items that are not durable at all because they get used up, for example, lancets and glucose monitor test strips. And the rules on what DME you are "allowed" to buy from a pharmacy in order to have coverage are Byzantine. This summer I found out that my pharmacy was not a DME provider for crutches, but it was a DME provider for lancets and test strips, which was a distinction that was never satisfactorily explained to me.
Aside from the possible gap in fills, here are significant
differences between the 2017 formularies of the two PBMs (the new one, of course, seems more restrictive than the old), so which PBM will be in place for the future is actually important for me to track down.
I have asked both Aetna and Health Advocates for information and we'll see who can clarify it first.