Therapeutic Interchange: How It Could Affect Patients

Therapeutic Interchange: How It Could Affect Patients

By Steven R. Ariens, P.D. R. Ph.

Earlier this month CVS Health stated that it is using various tools to help keep the inflationary cost of medication down to 0.2%

How CVS kept drug costs down despite soaring inflation? (Check Here)

One of their methodologies that is mentioned at face value sounds rather benign, but according to Jon Roberts, executive vice president and chief operating officer, CVS Health. “At CVS Health, we always encourage the use of clinically appropriate therapeutic alternatives including generics.”

Steve Ariens

“The lower cost growth was due in part to utilizing low-cost generic drugs, which were dispensed to 86% of pharmacy benefit management (PBM) clients.”

In other words, 17 out of 20 patients were moved to generics.

Pay attention to the phrase, “we always encourage the use of clinically appropriate therapeutic alternatives.” The term “therapeutic alternatives” means that CVS will be (somehow) getting patients to use a less expensive medication within a therapeutic category.

To use an extreme example of how this could play out:  Let’s take blood thinners, within that class are “new oral anticoagulants” which includes Paradaxa, Xarelto, Eliquis. These medications each costs several hundred dollars per month. The “old” generic anti-coagulant is Warfarin which typically costs a patient as little as $4.00/month.

When a patient uses Warfarin, there is no simple dosage transition between those new oral anticoagulants and Warfarin. The patient needs to adhere to some dietary restrictions and have lab/blood tests on a regular/ongoing basis.

In this example, there a reduction in the cost to CVS Health, but there are numerous costs that are shifted to the patient - as in co-pays – may be additional office visits and other costs to the patient’s insurance company.

How many dollars are saved and how many are shifted to other segments of healthcare that may (or may not) be less than the total monthly costs before therapeutic interchange was implemented.

Here is another process that CVS has recently implemented: “CVS Health introduced real-time benefits enabling prescribers to see the member-specific out-of-pocket costs of a prescribed medication as well as the costs of clinically appropriate alternatives in real-time allowing prescriber to make more informed decisions and offer members medication options that may be more affordable. “

Could this also include a message to the prescribers that the medication you chose for this patient requires a PRIOR APPROVAL but this other medication - same therapeutic category - is on the formulary and no further action/time needed on your part.

Since “time is money” -could this be the old “carrot & stick” motivational tactic? It may be hard to determine if cutting costs or patient’s health outcomes are CVS Health’s first priority?

Let’s see what happens—but be careful!

Steve Ariens is a retired pharmacist who is an advocate for chronic pain patients (his wife suffers from chronic pain). He is a frequent contributor to the National Pain Report.

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I am in the process of deciding whether or not to sue CVS. First, the pharmacists would refuse to fill my pain medications on the 15th day. This went on twice a month every month. This one pharmacist told me on many occasions that she decides when and if I need pain medications. She is not a doctor and (thank God) not my doctor. She has no access to my medical charts so she has no idea what my conditions are, nor why I am prescribed medications. Then this pharmacist who finally filled my script after reporting her to corporate. I got home, opened up the bag to find the bottle of pills without a label. COMPLETELY ILLEGAL!!! They put me in a situation that God forbid if I had an accident (roads were extremely icy that morning) or been pulled over for any reason, I could have been arrested for having an unmarked bottle of pills. I also could have been charged with intent to sell as there were 60 pills in the unmarked bottle. I took pictures of the bottle full of pills unlabeled and I did report this to Corporate.

This all is completely unacceptable and needs to be addressed. As I said I am thinking about suing. I have to get through another neck surgery first on May 2nd, a cervical revision, as my first cervical fusion has completely failed. This has been going on for 3 years and have fought with different doctors but that is another story to be told.

BEWARE of using CVS Pharmacy.

Lisa Hess

CVS had lost me as a customer about 9 years ago. First they lost my opioid prescription. My doctor would not give me another prescription until CVS found the original one. Another time they had to order my Kadian because they didn’t stock it, BUT it could not be ordered for another 2 weeks when the pharmacy supervisor returned from vacation, then when that pharmacist supervisor quit the day she came back from vacation then I had to wait for a new supervisor to be “hired.” A couple of notes about some generics-no matter how many pharmacists say that the “generic is exactly the same as brand name” is a misnomer for several types of medications. Example, Percocet and Fentanyl patch. The generic forms are only at 40% efficacy of their Name Brand medication. For nine years I only used the name brand Percocet and Kadian until 2016 when Medicare stopped covering it under the third tier to the fourth and/or fifth tiers on their formulary and the patient has to be between 50-100% of the cost which is over $1K ea. per month. Same for some anti-depressants and especially Synthroid (synthetic thyroid medication). My doctor writes in large letters NAME BRAND SYNTHROID ONLY and if you are on Part D of Medicare in most cases they no longer cover any name brand opioids but they do cover name brand Synthroid. Go Figure!

Alan Edwards

A comment in a previous article is correct INTRACTABLE pain is the correct medical, scientific term for most of us who are suffering now during this horrible time.

CVS is full of problems and some pharmacists do mistreat patients. Most pharmacy technicians do not. Their policies are rooted in maximizing profits. The kind, compassionate CVS employees are sometimes vocally critical of their colleagues who shame intractable pain patients. I have seen it happen and the technician was defending me after a doctor submitted a misdated lortab prescription. What a human being she is. She is not in the majority, however.

Like Suzanne and Amy I too absolutely despise CVS. To the point where I REFUSE to darken their door’s anymore, for anything. Eight years ago they refused to fill my medicine on the 31st day. It was prescribed for every 30 days with refills. The pharmacist claimed it had something to do with the previous month having 31 days in it, so there hands were tied. I don’t care how many days are in the month, I expect my medicine to be filled on the 31st day when I am out and have refills. I called another CVS Pharmacy to try and get answers. The next pharmacist explanation to me as to what happened was, “The doctors don’t get to play God anymore; WE DO!!! The doctor at the emergency room found this more than interesting. He was livid as a matter of fact. In keeping my medicine from me, it cost me a trip to the hospital. This happened on a Friday evening so there was nothing my doctor could do until Monday. It’s not like you can call them at home and say look, CVS won’t let me have my medicine because of the number of days in the month, not to mention the fact that they’re being imbeciles. The very next week I found a lovely little mom and pop pharmacy. One that treated me with respect and cared about my health as well as my feelings! I’m an excellent customer and treat my pharmacy staff whoever they may be with the utmost respect and courtesy. My pharmacists and staff are just as important to me as my physician is. When it involves your life and your health they play a major role in being just as responsible. It took me what seemed a lifetime to find a doctor and pharmacy that truly cared whether I lived or not. Thanks to God I finally have both now and truly don’t know what I would do or where I would be without either of them. Also there is a reason that medicines are brand and generic. When it comes to my thyroid medicine, the brand works the generics do not. There are four of my prescriptions that if are changed to another pharmaceutical company, I get drastically sick. It’s just not a one-size-fits-all world when it comes to medicine. I find it appalling that a pharmacy would want to play Russian roulette with someone’s life just to save a few bucks. If you’re one of those who deal with CVS, you need to go while the going’s good.

Amy Hartmann

I am not sure I understand the issue of this story - the idea that a patient may be switched to a lower cost alternative within the same therapeutic class? Or that a prescriber might opt for a different medication if it means they don’t have to do any additional paperwork? Or that a patient who is requesting a brand name drug would be refused that drug?

Listen, I despise CVS/Caremark and all they stand for in the healthcare industry. I think their PR folks are full of lies and spin, so I’m not an apologist by any means. However, I do think it’s misleading to say 17 out of 20 patients were moved to generics - generally speaking, and as is the law in many states, that unless the prescriber specifically states “Brand Name Requested”, the generic drug is dispensed. The practice of dispensing generic alternatives (and by that, I mean alternatives to the brand name drug) is the norm (at least in most states).

And while I appreciate the example given, I have yet to encounter a prescriber who wants a Factor X inhibitor be swayed to put their patient on warfarin instead - they really aren’t therapeutic equivalents in the truest sense of the term although they do both have the same end result (thinning of the blood). A more accurate example would be that a physician requests Effient but the patient’s formulary covers Brilinta instead.

I actually think that real-time notification to the physician could be a good thing. Imagine not having to wait until you arrive at the pharmacy to find out that the medication prescribed is not being covered by your insurance? If the prescriber can be told that before you leave the office, you will be better informed about what is happening (are they going to do a prior authorization? Or switch drugs?) and perhaps experience less frustration with the process. Of course, PBM’s could do dastardly things, which they already do, but with many organizations advocating for increased transparency, perhaps the result of this won’t be a big negative for everyone.

And as for the drum I always beat - YOU are your own best advocate. If you don’t want to be switched (for whatever reason - you’ve tried and failed a certain drug, you already know something doesn’t work, etc) - tell you prescriber and tell your pharmacist. You have the ultimate authority about what you get (just know that your insurance isn’t required to cover it).

Kris Aaron

I’ve discovered that prescription medicine from overseas pharmacies costs anywhere from 50% to 90% LESS than what is available from US pharmacies! Additionally, many drug providers outside the country don’t require a prescription to fill a non-opioid order.
For example, the price of a 45 gram tube of Retin-A was increased by the manufacturer from $65 to almost $300 — the pharmacy in India mailed it to me in less than 10 days for $60 including the cost of shipping!
As far as I can determine, overseas pharmacies offer similar quality and service at far lower cost than their American counterparts. Frantic warnings about the “dangers” of drugs manufactured and sold in other countries are beginning to sound like nothing more than marketing hype, especially when local drug stores play CVS-style games with our medicines.

Since pharmacy benefits managers receive no education in medicine or pharmacology, their efforts to practice medicine without a license pose an obvious danger to patient’s lives.

The only real solution here, is for patients to unionize, so that large groups of patients can collectively withhold tens of billions of dollars in premium payments from insurers, until insurers actually deliver the benefits that they promised to deliver, when signing contracts to insure patients.

Single-payer systems run by politicians, and geographic monopoly systems such as Obamacare that pretend not to be single-payer systems but function as such, interpose ignorant money-counters between patients and our doctors. Unless we patients can command the ignorant money-counters to deliver the care we seek, these healthcare monopoly systems will continue to deliver worse care at higher costs, because they empower the ignorant money-counters to bleed money from patients to pay for more money-counting.


BOYCOTT CVS. They are discrimatory to chronic pain patients because is their restrictions on pain medications. Don’t be fooled by these come on new programs. I will not set foot in their store.