Linda Cahn is the founder and president of a nationwide consulting firm, Pharmacy Benefit Consultants. The firm assists corporations, unions, government entities and insurance companies in improving their prescription coverage benefits and decreasing their prescription coverage costs.
Cahn’s expertise related to prescription coverage arises from lawsuits she filed on behalf of clients against pharmacy benefit management companies (PBMs). In 1997, she initiated the first class action litigation against the two largest PBMs at that time—predecessor entities to Medco Health Solutions and CVS Caremark. As a result of that litigation and several subsequent lawsuits, she gained access to hundreds of thousands of confidential PBM documents.
In the United States, a pharmacy benefit manager (PBM) is a third-party administrator of prescription drug programs for commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program, and state government employee plans. According to the American Pharmacists Association, "PBMs are primarily responsible for developing and maintaining the formulary, contracting with pharmacies, negotiating discounts and rebates with drug manufacturers, and processing and paying prescription drug claims. For the most part, they work with self-insured companies and government programs striving to maintain or reduce the pharmacy expenditures of the plan while concurrently trying to improve health care outcomes." PBMs operate inside of integrated healthcare systems, as part of retail pharmacies, and as part of insurance companies.
Medco Health Solutions, Inc. was an American Pharmacy Benefits Management (PBM) company which served more than 65 million people, before it was ultimately acquired by Express Scripts in April 2012. Medco provided pharmacy services for private and public employers, health plans, labor unions, government agencies, and individuals served by Medicare Part D Prescription Drug Plans. Medco was a member of the S&P 500 and ranked number 34 on the 2011 Fortune 500 list, with 2011 revenues of more than $70 billion. It earned the No. 1 ranking in the Healthcare: Pharmacy and Other Services category on Fortune magazine's World's Most Admired Companies list for five consecutive years (2008-2012).
CVS Caremark is the prescription benefit management subsidiary of CVS Health, headquartered in Woonsocket, Rhode Island.
Cahn has testified before state legislative hearings about proposed legislation to alter PBMs’ practices and improve the prescription coverage marketplace. She has also conducted numerous meetings about PBMs with federal and state prosecutors, officials at the Government Accounting Office and the United States Labor Department, and on Capitol Hill.
Capitol Hill, in addition to being a metonym for the United States Congress, is the largest historic residential neighborhood in Washington, D.C., stretching easterly in front of the United States Capitol along wide avenues. It is one of the oldest residential neighborhoods in Washington, D.C., and with roughly 35,000 people in just under 2 square miles (5 km2), it is also one of the most densely populated.
She is a graduate of Princeton University and Hofstra Law School, both with honors.
Princeton University is a private Ivy League research university in Princeton, New Jersey. Founded in 1746 in Elizabeth as the College of New Jersey, Princeton is the fourth-oldest institution of higher education in the United States and one of the nine colonial colleges chartered before the American Revolution. The institution moved to Newark in 1747, then to the current site nine years later, and renamed itself Princeton University in 1896.
Prescription drug prices in the United States have been among the highest in the world. The high cost of prescription drugs became a major topic of discussion in the new millennium, leading up to the U.S. health care reform debate of 2009, and received renewed attention in 2015. High prescription drug prices have been attributed to government-granted monopolies to manufacturers and organizations lacking ability to negotiate prices.
A prescription drug is a pharmaceutical drug that legally requires a medical prescription to be dispensed. In contrast, over-the-counter drugs can be obtained without a prescription. The reason for this difference in substance control is the potential scope of misuse, from drug abuse to practicing medicine without a license and without sufficient education. Different jurisdictions have different definitions of what constitutes a prescription drug.
CVS Pharmacy is a subsidiary of the American retail and health care company CVS Health, headquartered in Woonsocket, Rhode Island. It was also known as, and originally named, the Consumer Value Store and was founded in Lowell, Massachusetts, in 1963. The chain was owned by its original holding company Melville Corporation since its inception until its current parent company was spun off into its own company in 1996. CVS Pharmacy is currently the largest pharmacy chain in the United States by number of locations and total prescription revenue. Its parent company ranks as the 7th largest U.S. corporation by FY2017 revenues in the Fortune 500. The parent company of CVS Pharmacy's leading competitor ranked 19th for the same time period.
California Proposition 78, the Prescription Drug Discounts Initiative, was rejected by voters in the California special election, 2005. According to a press release from the office of the California Secretary of State, Bruce McPherson the proposition summary was:
California Proposition 79 (2005) was an initiative in the November 8, 2005 elections that covers the areas of Prescription Drug Discounts and State-Negotiated Rebates.
Medicare Part D, also called the Medicare prescription drug benefit, is an optional United States federal-government program to help Medicare beneficiaries pay for self-administered prescription drugs through prescription drug insurance premiums. Part D was originally proposed by President George W. Bush in 2003 and enacted as part of the Medicare Modernization Act of 2003 and went into effect on January 1, 2006.
Express Scripts Holding Company is an American Fortune 100 company. As of 2018, the company is the 25th-largest in the United States by total revenue as well as the largest pharmacy benefit management (PBM) organization in the United States. Express Scripts had 2016 revenues of $100.752 billion. Since December 20, 2018, the company has been a subsidiary of Cigna.
The Medicare Part D coverage gap is a period of consumer payment for prescription medication costs which lies between the initial coverage limit and the catastrophic-coverage threshold, when the consumer is a member of a Medicare Part D prescription-drug program administered by the United States federal government. The gap is reached after shared insurer payment - consumer payment for all covered prescription drugs reaches a government-set amount, and is left only after the consumer has paid full, unshared costs of an additional amount for the same prescriptions. Upon entering the gap, the prescription payments to date are re-set to $0 and continue until the maximum amount of the gap is reached OR the current annual period lapses: copayments made by the consumer up to the point of entering the gap are specifically not counted toward payment of the costs accruing while in the gap.
CVS Health Corporation is an American retail pharmacy and health care company headquartered in Woonsocket, Rhode Island. Consumer Value Stores (CVS) began in 1963 with three partners, brothers Stanley and Sidney Goldstein and partner Ralph Hoagland, who grew the venture from a parent company, Mark Steven, Inc., that helped retailers manage their health and beauty aid product lines. The business began as a chain of health and beauty aid stores, but within several years, pharmacies were added. To facilitate growth and expansion, the company joined The Melville Corporation, which managed a string of retail businesses. Following a period of growth in the 1980s and 1990s, CVS Corporation spun off from Melville in 1996, becoming a standalone company trading on the New York Stock Exchange as CVS.
In managed medical care step therapy is an approach to prescription intended to control the costs and risks posed by prescription drugs. The practice begins medication for a medical condition with the most cost-effective drug therapy and progresses to other more costly or risky therapies only if necessary. Also called step protocol or a fail first requirement, and is a type of prior authorization requirement.
Electronic prescribing is the computer-based electronic generation, transmission, and filling of a medical prescription, taking the place of paper and faxed prescriptions. E-prescribing allows a physician, pharmacist, nurse practitioner, or physician assistant to use digital prescription software to electronically transmit a new prescription or renewal authorization to a community or mail-order pharmacy. It outlines the ability to send error-free, accurate, and understandable prescriptions electronically from the healthcare provider to the pharmacy. E-prescribing is meant to reduce the risks associated with traditional prescription script writing. It is also one of the major reasons for the push for electronic medical records. By sharing medical prescription information, e-prescribing seeks to connect the patient's team of healthcare providers to facilitate knowledgeable decision making.
Based on the National Council for Prescription Drug Programs standard, all pharmacy software systems contain information fields for both a primary and secondary insurer to pay for patient’s prescription. The co-pay card appeared in 2005 as a means by which pharmaceutical marketers could, by offering an instantaneous rebate to patients, combat their challenges to prescription pharmaceuticals, including generic competition, lack of patient compliance and persistency, and an access to the physician population. As of January 2017, in the United States, coupon cards for more than 600 prescription medications are available.
A drug coupon is a coupon intended to help consumers save money on pharmaceutical drugs. They are offered by drug companies or distributed to consumers via doctors and pharmacists, and most can be obtained online. There are drug coupons for drugs from many categories such as cholesterol, acne, migraine, allergies, etc.
Catamaran Corporation is the former name of a company that now operates within UnitedHealth Group's OptumRX division. It sells pharmacy benefit management and medical record keeping services to businesses in the United States. Working independently of the government and insurance companies allowed it to operate as a third party verifier; the RxCLAIM online claim processing system allowed for prescription drug claims to be processed online if the customer lived in and filled his/her prescription in the United States. SXC had three separate but interrelated business segments which dealt with prescription drug programs. For 2013 23% of company revenue came from Cigna Corporation.
Specialty drugs or specialty pharmaceuticals are a recent designation of pharmaceuticals that are classified as high-cost, high complexity and/or high touch. Specialty drugs are often biologics—"drugs derived from living cells" that are injectable or infused. They are used to treat complex or rare chronic conditions such as cancer, rheumatoid arthritis, hemophilia, H.I.V. psoriasis, inflammatory bowel disease and hepatitis C. In 1990 there were 10 specialty drugs on the market, in the mid-1990s there were fewer than 30, by 2008 there were 200, and by 2015 there were 300. Drugs are often defined as specialty because their price is much higher than that of non-specialty drugs. Medicare defines any drug for which the negotiated price is $670 per month or more, as a specialty drug which is placed in a specialty tier that requires a higher patient cost sharing. Drugs are also identified as specialty when there is a special handling requirement or the drug is only available via a limited distributions network. By 2015 "specialty medications accounted for one-third of all spending on drugs in the United States, up from 19 percent in 2004 and heading toward 50 percent in the next 10 years", according to IMS Health, which tracks prescriptions. According to a 2010 article in Forbes, specialty drugs for rare diseases became more expensive "than anyone imagined" and their success came "at a time when the traditional drug business of selling medicines to the masses" was "in decline". In 2015 analysis by The Wall Street Journal suggested the large premium was due to the perceived value of rare disease treatments which usually are very expensive when compared to treatments for more common diseases.
Specialty pharmacy refers to distribution channels designed to handle specialty drugs — pharmaceutical therapies that are either high cost, high complexity and/or high touch. High touch refers to higher degree of complexity in terms of distribution, administration, or patient management which drives up the cost of the drugs. In the early years specialty pharmacy providers attached "high-touch services to their overall price tags" arguing that patients who receive specialty pharmaceuticals "need high levels of ancillary and follow-up care to ensure that the drug spend is not wasted on them." An example of a specialty drug that would only be available through specialty pharmacy is interferon beta-1a (Avonex), a treatment for MS that requires a refrigerated chain of distribution and costs $17,000 a year. Some specialty pharmacies deal in pharmaceuticals that treat complex or rare chronic conditions such as cancer, rheumatoid arthritis, hemophilia, H.I.V. psoriasis, inflammatory bowel disease (IBD) or Hepatitis C. "Specialty pharmacies are seen as a reliable distribution channel for expensive drugs, offering patients convenience and lower costs while maximizing insurance reimbursements from those companies that cover the drug. Patients typically pay the same co-payments whether or not their insurers cover the drug." As the market demanded specialization in drug distribution and clinical management of complex therapies, specialized pharma (SP) evolved.„ Specialty pharmacies may handle therapies that are biologics, and are injectable or infused. By 2008 the pharmacy benefit management dominated the specialty pharmacies market having acquired smaller specialty pharmacies. PBMs administer specialty pharmacies in their network and can "negotiate better prices and frequently offer a complete menu of specialty pharmaceuticals and related services to serve as an attractive 'one-stop shop' for health plans and employers."
GoodRx is a website and mobile app that tracks prescription drug prices and offers drug coupons in the United States. GoodRx checks more than 75,000 pharmacies in the United States. The website gets about four million visitors a month.
The pharmacy management system, also known as the pharmacy information system, is a system that stores data and enables functionality that organizes and maintains the medication use process within pharmacies.