A prescription drug customer spent nearly a year trying to get a straight answer from CVS Caremark about why his maintenance medication kept arriving in 30-day supplies instead of the 90-day supply his doctor prescribed — only to discover he could buy the same drug for less money by paying cash at a local pharmacy.
The patient, a health policy professional writing for The Federalist, detailed his months-long ordeal navigating the opaque system maintained by CVS Health, one of the nation’s largest pharmacy benefit managers (PBMs). Despite having advocates from the District of Columbia’s Office of Health Care Ombudsman intervene on his behalf, he repeatedly received form letters stating his “prescription plan has limits on the amount of your medication it will cover” — without explanation of what those limits were or how to appeal them.
The medication in question was prescribed by his physician to prevent recurrence of kidney stones. Each time the doctor sent CVS Caremark a prescription for a 90-day supply, the PBM filled only 30 days’ worth, accompanied by the same vague notice about plan limits.
The Answer That Took a Year
After nearly 12 months of communications with CVS staff, the patient finally reached a representative who could explain the decision. His prescription plan covered the drug, but not as a maintenance medication — explaining why CVS kept reducing the supply from 90 to 30 days.
The representative informed him of an exceptions process through which his physician could submit a form to his insurer, CareFirst, providing clinical justification for using the drug as maintenance therapy. If approved, CVS Caremark would then honor the 90-day prescription.
The patient expressed frustration that he had specifically asked about the exceptions process when speaking with CVS personnel the previous summer — information he knew about from his work in health policy — but that representative never provided the details that could have saved months of hassle.
A Web of Responsibility
When the patient contacted CVS’s corporate office asking why the notices used deliberately vague wording about “your prescription plan” — rather than clearly identifying whether his insurer or the PBM made the coverage decision — and why they didn’t include written instructions for requesting an appeal, CVS’s response introduced yet another layer to the decision-making process.
According to CVS’s communications team, “CareFirst is the plan sponsor, and CVS Caremark helps support the administration of the plan’s pharmacy benefit. This CareFirst plan relies on an expert third-party vendor, Medispan, to determine which medications are considered maintenance drugs versus acute. Because Medispan lists potassium citrate as a non-maintenance drug, it is subject to the CareFirst plan’s non-maintenance day supply limit of 30 pills.”
The response revealed that a previously undisclosed third party — Medispan — had actually made the determination limiting the prescription, while still not addressing why the notices omitted information about filing an exceptions request.
The Cash Alternative
Ultimately, the patient decided that fighting for 90-day coverage through CVS Caremark was wasting both time and money. Research into cash-pay alternatives revealed dramatic price differences.
CVS Caremark charged him $45.81 for the prescription. By contrast, Cost Plus Drugs would charge $10.93 plus shipping for the same medication, while Pharmacy Checker listed prices as low as $17.27. Using a discount code at a local grocery store pharmacy, he paid less in cash for a 90-day supply than CVS Caremark would have charged for another 30-day prescription.
While paying cash means the prescription cost won’t apply to his annual insurance deductible, the patient noted he’s on an Affordable Care Act plan with a deductible he won’t meet anyway “unless I have a major medical emergency.”
The Profit Motive
When asked about the pricing disparity, CVS’s communications team stated that “the same medication can have different member costs depending on the plan and pharmacy selected.” However, according to The Federalist, previous reporting has documented how health care conglomerates like CVS often overcharge customers for prescription drugs as a way to shift profits from their insurance business — where the Affordable Care Act’s medical loss ratio caps profits — to their pharmacy business, where no such caps exist.
The medical loss ratio provision in the ACA requires insurers to spend at least 80% to 85% of premium revenue on medical care and quality improvement, limiting the percentage they can keep as profit or spend on administrative costs.
The patient’s experience illustrates how PBMs can profit from maintaining a complicated, bureaucratic system while patients who pay cash can access the same medications at significantly lower prices. His advice to other consumers: look into all available options, because paying cash could save substantial money and time.
Source: thefederalist.com — https://thefederalist.com/2026/08/03/how-obamacare-pushes-big-pharma-to-overcharge-you-for-prescriptions/