A Behemoth is Born

CVS bought Caremark Rx. Read this carefully: Caremark has been sold. More predictions come true, and the rapid acquisitions of specialty pharmacies continue at a dazzling level.

Caremark Rx, Inc., located in Nashville, Tennesee, is the nation’s second-largest PBM. Caremark Rx has recently approved a $27 billion takeover by CVS. The acquisition has created a behemoth with the power to define, redefine, and direct the nation’s pharmacy distribution system. CVS/Caremark will have combined sales of more than $80 billion and rank among the top 20 Fortune 500 companies. Express Scripts, the number three PBM in the country, attempted a hostile takeover of Caremark in 2006. What will Express Scripts do next? Who might they purchase instead?

It can’t be stressed more strongly: Hemophilia patients must follow the rapidly changing acquisitions to know where their health benefits and service will originate, how this will affect their treatment and care, and where their health dollars will be going. For now, it looks like a lot of healthcare dollars will go to Wall Street.

Which Suitor is More Attractive?

Far more interesting than watching Pamela Anderson and Kid Rock or Britney Spears and what’s-his-name marry and divorce is the romance going on between PBMs and certain homecare companies. Express Scripts is one suitor that doesn’t give up easily. Last week I told you that Express Scripts made a hostile bid for Caremark; Caremark jilted it this past week. It prefers the attentions of CVS, which has also bid for its hand. Those of you who use Caremark for your homecare needs better pay attention; and those of you who don’t better pay attention. The marriage of any of these giants is going to continue to impact our community, directly and indirectly. Although allegedly all this wedded bliss is supposed to lower prices of drugs, it remains to be seen in the hemophilia bottom line. What it will do for certain is consolidate power— and squeeze out the market share of smaller homecare companies who are not owned by large specialty pharmacies or PBMs.

Caremark shareholder approval of CVS or Express Script (most analysts are betting on CVS) is the next thing to watch. Tune in—

Book I read this week: “Thunderstruck,” by Erik Larson. **** Four stars
Fascinating true account of a murder mystery in London that riveted the world, and the parallel invention and development of the wireless by Marconi— and how these two events eventually crossed paths with explosive and fateful consequences. Great reading!

Monstrous Acquisition of Factor Providers Looming

Happy new year! We’re off to an exciting but challenging start to this year in the bleeding disorder community. Witness what is happening right now, that should have you sitting bolt upright: a hostile takeover bid for Caremark. Do you use Caremark as your homecare company? Keep your eye on what is happening.

A year ago, my newsletter PEN predicted that specialty pharmacies would continue to merge as the home care industry faced unprecedented change while battling the “coming storm” in the insurance industry. Cost-cutting methods by payers are forcing the industry to rethink how it does business; and mergers provide ways to gain power, market share and possibly lower prices.

We’ve seen a tremendous number of mergers and acquisitions, but nothing on the scale of what is happening now. Express Scripts, one of the nation’s top pharmacy benefit managers (PBMs), has launched a hostile bid for Caremark, one of the largest factor providers, and also a PBM. The surprise $26 billion bid came in December.

In “Taking Center Stage” (PEN, May 2005), PEN explained that PBMs are business middlemen hired by employers and insurers to negotiate better prices from drug manufacturers and retailers. They encourage employees to use lower-priced generic drugs and less expensive mail-order pharmacies. PBMs are hired to save employers money by managing healthcare contracts and costs. But in the current wave of mergers, PBMs are emerging with great power, and can exert strong influence over pricing, especially for biological products like factor.

The Los Angeles Times predicts that the Express Script/Caremark combined company will control about 30% of the total PBM market, with $49 billion a year in revenue. That’s compared to its next biggest rival, Medco (which owns Hemophilia Health Services), with $38 billion a year in revenue. The LA Times also notes that not everyone is confident that more consolidation is good. There’s no guarantee that this merger will eventually pass along savings to employers and employees, including those with hemophilia. It’s true that the merged company will be the most powerful in factor distribution. Smaller, independent factor providers–a traditional and important part of the bleeding disorders community–face troubled times ahead as they play David to the industries’ newly-created Goliaths.

For more information, see “Express Scripts tops CVS in hostile bid for Caremark Rx.” Daniel Costello, Los Angeles Times, December 19, 2006, and visit archived article at

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