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PBM Failures Drive Patients Abroad for Meds" explores how rising drug costs and restrictive practices in the U.S. force patients to seek medications internationally. Theo Symons and Semion Naidis of ILMEDS share how they provide affordable, regulated name-brand drugs, navigating complex legalities and emphasizing transparency, patient care, and quality. A timely discussion on breaking barriers in healthcare access.
This transcript was generated automatically. Its accuracy may vary.
Mike Koelzer: Theo, introduce yourself to our listeners.
Theo Symons: my name is Theo Simons. I'm a co-founder and COO of IL Meds. We are [00:01:00] an international mail order pharmacy. technically IL Meds is a medication logistics company, but practically we are an international mail order pharmacy.
Theo Symons: We offer savings on name brand medications. We offer anywhere between 40 and 80 percent discount from U. S. retail. We currently are active in a few different sectors.
So we have a lot of business in direct primary care. what that means is We essentially partner with, direct primary care physicians, clinics for, different ailments and, they refer their patients, to us to,
afford them the opportunity at purchasing, name brand medications at much cheaper rates than is currently available in the States.
All right. So Theo,
Mike Koelzer: when you reached out to me, my first thought was international brand name drugs. Well, that's gotta be tricky. And I thought not only tricky, but how do they do that? How do they legally do that?
And then I thought to [00:02:00] myself, this goes back to the old days of other countries bringing in brand name drugs and trying to undercut pharmacies and all that. Well, then. three or four years ago, I stopped carrying brand name in my pharmacy because the PBMs, are you familiar with PBMs?
Theo Symons: Sure. I would love to speak about that too.
Mike Koelzer: So the PBMs in,in
America, they paid us like 10 percent below cost. And so every day I'd buy 10, 000 in medicine
and I would get like 9, 000 in payment, , like a month later. And so about three years ago, we stopped
carrying brand name drugs. I get upset with our system, which of course we're fighting over here in the U S against the pharmacy benefit managers.
I get upset where I'm caring for all the people in
My neighborhood and I cannot supply their brand name medicine. not only
can I not supply it, I then can't supply the [00:03:00] care that goes along
with it, the questions they might have for me and dosing and all that
kind of stuff.
Well, screw it. I said, if I can't do it, I'm going to bring Theo on here and at least see what he has to say. But I warned you. I said, now Theo,
we're in the U S here. A lot of rules, a lot of state laws and all that stuff. So I said, I'm going to play a lot of
devil's advocate on you and you agreed to
come on.
And so I'm happy to have you
here.
Theo Symons: So let's take it,
one question at a time, let's start at the
beginning and we can work our way through.
First question, legality, right? Obviously a big
question, an important question. Understanding the regulations on a federal level and on a
The state level is absolutely crucial. And that is one
thing which we
went through, know, with a, with a toothpick to make sure that we
were, in
the legal frameworks
under which we were operating, that
We fulfill all of our regulatory obligations.
So on a very basic
level. The [00:04:00] FDA has a personal importation clause that allows for US
citizens
to import up to three months of a particular assuming it's not a controlled substance. So for example, we don't
import
anything, like, um,any ADHD medication, Adderall, Vyvanse. Those kind
things are off the table. Um, there's no real regulatory
structure that would allow us to sell
those kind of
things and
for the
patient to then import them. Um, so on a federal level, we follow the
FDA. Personal importation, clause and guidelines. And
on a state
level, and as far as our
legal team could tell, the state laws really
only relate to pharmacy
importing drugs into the state, and all of the regulation that
follows that.
Our legal structure and the relationship that we
maintain the
patient who receives the medication at the end of the
day is the
transaction for the medication takes place outside of America, in this case [00:05:00]
in Israel. And then the patient uses our company to send them the medication, but they
are
the ones who are importing. So when it comes to the
state laws pertaining to pharmacy importation of medication, we actually don't fall under that category. on a federal level. We strictly adhere to the personal importation guidelines. So that also
means, for example, we're never going to send a
patient more than uh, 90 day supply of
any particular medication. and we're not going to supply
anything that's narcotics, um, amphetamine medications.
Mike Koelzer: The three
month thing, that's interesting. I've never thought about it. Never knew it.
I know people always
got stuff from Canada. So I'm assuming that international
trade of some
sort is okay. are there any loopholes do they
say three months, but you have to be visiting or this or that, or is it
just a clean
three months that that's all they can get?
In other words, there's no loop you're jumping around. That's just the law.
anybody
can get three months from out of the
country.
Theo Symons: So I can read you the exact
language from the FDA personal importation clause because [00:06:00] it is actually somewhat ambiguous. Uh, so it
says the FDA will allow, generally up to a 90 day supply
of drug products. So we, we aren't going to play with the ambiguity of
the FDA. We like to stay firmly within the legal boundaries that we know and understand
can, and can make a guarantee on. know, every, everything
that we ultimately send to the patient is declared both on the Israeli custom side
and, to customs when it reaches the us. Sothere's
absolutely nothing that's, that's hidden. Uh, we uh, the medication, the, the quantity, the, the price that's being sold for in every
these are kind of, the, the other
details of that FDA clause that We have to include proof of prescription by a U.
every package that we send
Mike Koelzer: All right. So Theo, here's one of these
devil's advocates thing that I'm going to keep throwing out
at you. So is there anything else in that clause though? I mean, does it [00:07:00] stop there or does it go on to say
any, qualifiers or anything that
import law,
Theo Symons: So the import is relatively short. It's really only about two or three
paragraphs, and then it moves on to foreign nationals and
other categories. When it comes to the U. S.
two categories for drugs that they're able to import. Those two categories are
products that are not for the treatment
of a serious condition, and there is no known significant health
risk.
Or if the product is for the treatment of a serious condition, there's a list of allowances that
would allow you to import the drug. So for example, one of them is the product. An unreasonable risk. Now, what is an unreasonable risk?
The FDA. never really clarifies what those terms mean.
uh, we've, we've not encountered a you know, we've, we've now been able to connect with thousands of patients across the U. we, and we, you know, occasionally [00:08:00] we will have packages that are stopped at customs that are opened.
Sometimes they require extra documentation. Normally, it's just us resending
them the documentation that we'd included in the you
know, that extra reassurance, but we've never had a package Stopped in customs and not released so far.
Mike Koelzer: Talking about
state laws.
as far as I know, in our
pharmacy, if I wanted to mail into
another state,
I don't even know if it
allows
for if someone's on vacation somewhere, because some of these laws
just
say you cannot mail into that
state unless you're licensed in the state.
devil's advocate,
I could say, well, I'm not doing the transactions in the
state. I'm doing it in my cash register in Michigan.
going to the post office in Michigan and boxing it
no transactions
have
taken place in their state. As far as I know, the laws don't say that [00:09:00] they
just say no mailing into the
state. Now
That's our state's rules. And maybe the federal rules
I know usually they'll go with the most strict of the
rules, but maybe they allow for
some of that. So hearing what I
just said That I can't go into
other
states. What are your thoughts on that? Do you think it's different for your
pharmacy or how do you
see that?
Theo Symons: Yeah, those that's
absolutely a fantastic question and
I appreciate Uh, you playing devil's advocate it, it, it gives me the opportunity to
sharpen, uh, the explanation of, of, of, how we function and how
we work, um, in, in light of those um, so the key difference between what you said and what we do is that, I,Elmed, officially, legally, Milenkovic
is a separate company from the pharmacies that are owned by the same owners.
So
because it's a different legal entity, the purchase of the
drug, we're essentially [00:10:00] given
power of attorney by the patient. which is all in our terms and conditions And when it employer benefits that we provide and and us having that power of attorney for Because of that, the
The transaction is really taking place in Israel. It's as on, a, uh, a legal framework, it is
as if the patient is making that purchase in Israel and then sending it back to themselves in the United States. So that would be the fundamental difference.
Mike Koelzer: I see.
So in my language that would be like
if, somebody's. Grandma came in on
behalf of their grandchild, who's going to college
somewhere. She came in, had, the power of
attorney said, I'm buying it for my
grandchild. I'm in Michigan. You're in Michigan.
This transaction happened in
Michigan, but now I'm going to
mail it to my grandson. who lives eight states away, but as the grandma, I don't fall under the state
rules of what
this pharmacy can [00:11:00] do out of state. This is grandma
to my grandson.
Theo, I'm out of them. So you tell me some tricky ones and other kinds of questions. Have you had to come across either in your own mind, you thought of
them or people have challenged you, what other ones have you dealt with? And how do you answer those other ones?
Yeah. So one of the really common questions that we get asked when we first started Uh, this
Theo Symons: project of kind of going international. Originally, our company is, um, just a domestic, uh, chain of
regular pharmacies functioning here in Israel, we have four branches in four different
cities. were doing, we were doing quite well.
And, we saw this huge disparity in the pricing of specifically obesity medication. So, you know, the Ozempics, Wegoby, Ribelsis, the GLP 1s, the name brand medications.
And, um, I'm sure you're familiar that compounding it's become somewhat of a wild west in
the States, uh, when it comes [00:12:00] to obesity medication. Um, you know, the uh, on semaglutide from Novo Nordisk isn't it's only, it's only up at the
you know, in mid 2026. um, The source
of the semaglutide is not always
the question that we were most commonly asked
was, you know, how to source the drug for such a significant
uh, and is it compounded? That was always, you know, the first, the
First two questions. Um, and so I would
like
to give a couple of um, why the price disparity Uh, and then
why there's really no reason to be concerned when it comes to drugs coming from Israel. So first we'll delve into the regulatory nitty gritty.
So essentially in most of the
developed world. You have regulatory bodies that will barter with pharmaceutical
companies And determine how much they value the new drug they're bringing to market. you know, so for example, you could have an
existing medication that's 30 percent
effective for a particular [00:13:00] ailment, and the new drug is 40 percent effective.
And so this particular governmental body will turn to the pharmaceutical company and
say, What you're
bringing to the table increases
the effectiveness of treating this illness by 10 percent and this is how much we're willing to pay
for that increase in ineffectiveness and 99 times out of 100 it's valuable for the pharmaceutical company to open up a new market
go into a new country And sell their product there.
In the United States, no such
regulatory body exists There's really no regulation at all for the price of new drugs coming to market You And ultimately, there's kind of a, an interesting relationship between the United States and the rest of the world the thing that facilitates the cheaper price in the rest of the world is that it's so expensive in the United States.
Uh, but that's really the crux of why there's such a price disparity. And if I can move on to my second question about
compounded. So in Israel, um, the health ministry is Milenkovic is [00:14:00] exceptionally stringent on everything, they love regulation, really. Anytime they find an opportunity to add more rules, that is their forte.
Uh, when it comes to compounding, you are not allowed to compound a drug that is currently available on the market. Um, so, so in Israel, we, uh, thankfully don't suffer from the same obesity epidemic that's taking place in the United States. Um, and we've really not experienced shortages of, of these GLP 1s, the name brand GLP 1s that have either been hard to find in the States or when they are available, uh, they're extortionately Um, so we really Um, no opportunity, even if we wanted to, but, you know, for the legal swamps that a person would be wading through to deal with compounding a drug where the patent is still active, it's not something that we're interested in doing, and the regulation just doesn't allow us to.
So for those two reasons, uh, in addition to being a TAA compliant [00:15:00] country and a tier one country, uh, we're able to uh, good manufacturing standards that are maintained by the EU. Any drug that is released in Israel has already been released in America and FDA approved. So for technical reasons, we can't say drugs produced outside of the States are FDA approved, uh, just because it's a regulatory body that Uh, deals with the United States, but any drug that, that reaches Israel has already gone uh, process of all different, uh, stage trials a drug has to get through in order to, to get that stamp of approval by the FDA.
Mike Koelzer: So the argument there is that, we're giving you a brand name medicine at the same price as Joe's Pharmacy is compounding, generic for, and hopefully Joe's is a good pharmacy, but, there's always a chance of,
counterfeit drugs anywhere, but in general, you can say, look, here's the [00:16:00] brand name from the manufacturer, or you can get it from Joe's. And now you can choose and some people might say, I want it from Joe's, but some people might say, I want that name brand drug that came from the manufacturer. And you're able to do that then at, let's say a similar price as the compounded drug.
Theo Symons: Yeah, so that's actually, think, uh, pretty spot uh, in many, many cases. Particularly when it comes to the obesity that we carry. Our price for the name brand is close to, if not the same as, sometimes cheaper than what some companies are selling the compounded version for in the United I have a difficult time wrapping my head around. But that's just, that's what we're able to offer.
so Another question
we've recently
expanded into employee benefits because one of our, uh, founding values, one of our core values is [00:17:00] transparency. we have, you know, we have no problem sharing our profit margins. We have no problem sharing, uh, what the costs are in Israel. All of that information is readily Um, and we saw so much in, um, in the benefits markets. And, uh, you know, we've, we've been lucky enough to be connected um, some really wonderful people, some good needles in a haystack that seems like, uh, bad um, of people who really care about uh, value and, returning, returning care to healthcare.
You know, it sounds, it sounds cliche and
it sounds cheesy, but, but ultimately that's what it feels like. It feels like we're able to provide a that otherwise people either may not be accessing the medication or they
might be paying three, four, five uh, and So one of the questions that,that we've had to deal with is really finding out what the
markup for our company is, uh, particularly when it comes to pass through PBMs or, or brokers in, in having that, transparency upfront.
[00:18:00] for, for full disclosure, our markup as a company
for,
aisle When we, when we function through employee benefits
is between 10 and 20 percent. It never, never goes above 20.
Sometimes it goes below 10. But 20 is always the upper boundary of how much we are willing to make off of a particular the difference,
One of the classic examples we've had a lot of interest in recently.
Stelara, the injection for Crohn's that's taken bimonthly. So an injection that's taken six times a year and per unit in the States costs 26, 000, which is a price that is for
most people. Uh, really impossible to contend with. And so we offer the same, same, same name brand medicine for three and a half thousand dollars. And that, that allows these, um, these level health
plan brokers and, and pass through PBMs to offer a 0 copay to the member [00:19:00] and the employer also 60, 65, 70 percent discount from the 13, 000 they were paying when they were getting it locally.
So it's really transformative. Um, the model does exist, like you said, from, from Canada and other Uh,but our bottom line is we just have a better price point. Uh, we're lucky enough to, to be it, um, and to maintain the standards that we Um, we feel very privileged to be the ones to, to bring it to the
market.
Mike Koelzer: talked a little bit about PBMs and manufacturers. I don't give a rat's ass about either of them, I'm not even doing brand names because of those bastards. With that said, how do the manufacturers do it? Someone like you, do they get upset because now, Sally Jo, you know, living in the U S dumping 500 into the system and the [00:20:00] manufacturer making a decent cut of that.
Now, You're supplying them for, let's say 250, whatever you're supplying Sally, that medicine, do they frown on that with you? Do they say, Hey, we're selling it to you, Theo, and just lost us 250 bucks. Again, I don't give a, I don't give a damn about them, but will that catch up with you?
Theo Symons: It's a great question. I don't think so. If it did, we would be extremely successful at what we did. Ultimately, the , if, if we could cause enough of a commotion to get the attention of the drug manufacturers, we, you know, we'll be, we'll be on Cloud nine. We'll do it, the healthcare industry is so, so big.
There's so much money, particularly in the American healthcare system, that what we do doesn't, unfortunately, unfortunately, [00:21:00] it doesn't make a mark on the, on the industry at large. It doesn't have any impact on what the manufacturers make or, or can charge locally. We are not viewed as competition. I think a meaningful element of that is the, um, is the prohibition to sell wholesale.
So, you know, like I said, we can't ever sell to a pharmacy in the States. We can't ever sell to a hospital,
that we sell has to be patient specific. managed to, if we were to 50 X from where we are now, I still don't think we would be making enough movements to really get their attention.
Mike Koelzer: Yeah, that would be music to your ears if somebody started thinking you were doing too much of that, so That's
right. attention to us.
Theo, talking about
individuality of people, don't give me exact numbers, but I'd like to get a feel
of what are the mailing
rates? How long does that take? [00:22:00] Is that a problem? is there
any more problems doing that
than, know, mailing across
our country? What, What have you found far
as the
shipment And so on?
Theo Symons: So compared to a
local pharmacy, this is definitely one of the
areas where we, we fall down a little bit
in that our shipping times are between five
and seven working days, five to seven business days. So
we normally tell week, uh, from, from the time of dispatch. We've found in just in our own data that shipments
that are dispatched on certain days are faster than others. So we stopped dispatching on Thursdays, just because the, um, the packages that we would send would leave the country on the Sunday night flight anyway, and we had a pickup on Sunday. And when it comes to drugs like ozempic or WeCoV. Uh, or anything really that requires, uh, refrigeration, uh, that we send on ice packs in insulated packaging.
Uh, we prefer to
have as [00:23:00] short a transit time, as we can achieve. sometimes that's, you know, uh, four days from dispatch. Sometimes
That's eight days from dispatch, but generally it's around a week.
Um, the only time where we do have
Some upset is if, for example, a patient places an order immediately after the last dispatch we have for the week on a Wednesday, it means they're waiting until the Sunday for the order to
be dispatched.
So there's going to be
that added time where they're Um, we, we try to keep communication at, an absolute we have, um, emails that, that update, about if their package has been delivered. dispatched where it is in the process. There's tracking for everything provided at the point of dispatch.
So, as soon as it enters our courier system, the patient will receive an email with that tracking number. They can follow the whole process. Um, but it's not, it's not from today to tomorrow, you know, it's, it's not the next day delivery that you have from local pharmacies. And one of the other areas where [00:24:00] where we have, um, a lot of work is IVF and fertility medication.
Sometimes there are patients where their protocol needs to start, you know, the day after they've been in the doctor's office, so then that's not something that we can help with. as much as we would love to, because sometimes, specifically with IVF and fertility medication, the disparity is, is, know, I said at the beginning, our discount rates are between the 40 and 80 percent mark. And the 80 percent is unbelievable. due to IVF medication. We're able to offer discounts of, of, um, in, in that area. And, you know, it kind of allows us to give that stat, but it's, it's, it's really a sad reality, um, that the disparities are so huge.
A protocol that might, that,you know, an egg retrieval protocol that might cost the patient locally between, Uh, between 6, 000 to 9, 000, depending on their protocol. Our standard offering for [00:25:00] multiple clinics that we've worked with ranges between it's just, a world of difference.
Um, but like I said, if it's something that they need for the immediate, the immediate short term, unfortunately that's something that we aren't able to help with. even when we pay for, um, expedited delivery, it really only shaves off one, maybe two days,
um, on the delivery end.
Mike Koelzer: What does it cost to mail a package in general, not expedited, but just mailing from Israel to the U. S.?
Theo Symons: Expensive, is the, is the answer, um, but our average is between 35 to 55 if it's not expedited. Uh, but all of that generally is included in the cost. Uh, sometimes if the package is really cheap, uh, we might collect a uh, uh, shipping fee to kind of cover some of those costs, but we generally try to include it in the prices that we provide.
Mike Koelzer: and Theo, I'm imagining that your pharmacy, the patient then has the access to the pharmacy of, Speaking to a pharmacist online and all [00:26:00] that kind of stuff that, arguably it wouldn't matter if you're across the street online or across the world online.
You're talking to a health professional pharmacist and getting that same information you would with any online service. would?
Theo Symons: Yeah, we, we take
The service that we provide very seriously and the clinical staff that we have even more so. Um, we have, we, we try to be available for most hours of the day. We appreciate that there's a time difference. There's probably a five hour time slot Israel time between one and six a. m. where we're unavailable but really from from six in the morning through to one a.
but generally it's with him and that's something that we we offer and and um, that's an [00:27:00] essential part of of pharmacy, you know, I, I, I would be very suspicious of any online establishment that doesn't have that as an offered service, just because if you can't speak to a clinical professional when you're purchasing your medication, that's cause for concern.
Mike Koelzer: 20 years ago, when you started to hear about mail order pharmacy, pharmacists would say, well, you're not going to get the service you do face to face and they don't care and all this kind of stuff. Well, nowadays with all the cuts and the struggles that pharmacies have, let's say you and I were a pharmacist patient.
Pick which one of us is which I'd rather sit online with you right now in the privacy of my home, talking to you with undivided attention than I would going into a, Busy pharmacy where the pharmacist has pulled every different direction and they don't have time for you. the business isn't set up correctly [00:28:00] to make that happen.
There's no privacy. Now, the pharmacist is nodding after everything you say, just to get you out the door. And so have changed technology between video conferencing and, and being face to face.
Theo Symons: I think you touch on a really, really important point and, uh, I'm, I'm sure my colleagues, uh, would agree that the time we spend doing the international side is by far the most enjoyable, ultimately. Um, a you said, and a walk in pharmacy is not designed for privacy, and certainly when it comes to psychotropic medications, or, or, or anything that might come with a sensitive area of a person's life, Most, most most of the patients in those, in those categories, when they come in, are kind of whispering across, across the desk to, to let us know what, what medication they want us to, to, to fulfill.
Um, and the privacy aspect is really unmatched. [00:29:00] Um, and then you said. Um, it's just so difficult. Our core profession, obviously, is still domestic. Uh, the domestic chain of pharmacies and, and making sure they function to a high level of service, but it's incomparable. You know, it's like you said, it's just not the same when you have a carved out slot where you have the dedicated attention of that clinical professional to answer all your questions, to take you through the process from start to finish, to essentially, in a positive way, to through, uh, through the entire thing.
And it's just not possible in a traditional pharmacy setting. I think that's, uh, uh, incredibly, um, high value aspect. of what mail order pharmacies provide, uh, but obviously, like I said, you have to make sure that the, the mail order pharmacy that, that you're utilizing has those services available, um, and if not, that's, that's always cause
Mike Koelzer: I'm probably the first one to blame Our pharmacy, we have this long counter in front.
It's probably, I don't know, two [00:30:00] 20 feet long. We have three registers, so we can kind of squeeze down to the side and talk. And years ago, I tried to dividers with plexiglass and stuff, but we don't have
We have an area in our pharmacy where I can
go, I guess it'd be the office, kind of a patient office.
It could be, but I fight like hell not to go in there with somebody. You know, when somebody says, can I talk to you in your office? I'm like, like, Oh, that's not an office. You
Now, that's a broom closet. I fight like hell to go in there. Cause I got to sit down with Mrs.
Smith for 20 minutes and she's going to put her purse down and she's going to sit down
and, So I'll fight like to not sit down with
I'm to blame in
this, I'm, I'm to blame.
So full circle
to when we started the conversation. these PBMs slash manufacturers, whoever's to
blame.
We
can't sell brand names. I would rather send them to you
than [00:31:00] to force them to go to the vertically
integrated mail order
system
of the company that does not allow
me to go face to face with them One, kind of
piss on them, but two, I won't
believe they would give good service. I mean, they don't give a damn about us. So
Why would they give a damn about the customer? So all that talk Keep it in country, face to That's baloney because We're being
forced out of that.
So
While we were talking Theo, Semyon showed up on the
screen and he was going to be here from the start, but he's a pharmacist, head
pharmacist, Theo
mentioned him about the one that talks to a lot of the, the customers and he got pulled away on a medical call,
He joins us now. So Samian, nice to meet you. Thanks for
joining it.
So Semyon,
Semion Naidis: Thanks, Mike. Nice to meet you.
My name is Simeon. I'm the head pharmacist and founder of Isle Meds.
Mike Koelzer: [00:32:00] You should hear all that Thiel said about you. All my hard
questions he
said, wait till Semien gets here, he'll answer them.
Semion Naidis: I have the answers for you.
Mike Koelzer: Tell me about your guys relationship when it started
Semion Naidis: So we started working in the cannabis industry like three, four years ago, we started in the pharmacy in Beit Shemesh near Jerusalem. Then we opened two more pharmacies, one in Haifa and one in the southern part of Israel, which is Ashkelon. and After we opened these two pharmacies we started the international pharmacy business.
And then, because Theo is a native English speaker, we needed someone who, you know, represents us. For the customers, we serve in the U. S. and Theo was the obvious answer. He was the first one that I called and he just said, yes.
Mike Koelzer: Semyon, what's your pharmacy background as far [00:33:00] what kind of settings have you worked in and so on since you got your degree?
Semion Naidis: So I finished pharmacy school in Jerusalem in 2016, and then I worked for a big pharmacy chain. After two, three years in the pharmacy chain, I went to law school, and studied law. I studied patents and was like a patent agent in Israel for, like, two years. And after that, we had the opportunity to open the cannabis business here in Israel when they had a big reform here from cannabis being only on the farms and then patients just going straight to the farm and taking the cannabis from there. Then it, you know, they took it to the pharmacies and then patients come to the pharmacy and take cannabis from here, from the pharmacy. [00:34:00]
Mike Koelzer: Pretty much similar to the states here. A lot of the states have made it legal. Is it legal over in your parts Uh, Non medical?
Semion Naidis: No, it's Not legal. it's still a controlled substance and, you can only get it legally from a pharmacy
Theo Symons: was, I was just going to say a major difference between the States and Israel is that in the States you have specially dedicated dispensaries, for cannabis. Whereas in Israel, it all runs through regular dispensaries.
Mike Koelzer: Regular pharmacies.
Theo Symons: pharmacies.
Mike Koelzer: because
in the states, it's not necessarily legal. The feds still have it as a controlled substance. I think it might have gone from one to three last year. But
Semion Naidis: Right. Right.
Mike Koelzer: the states, like in Michigan, it's legal in usually the laws, whoever's, More strict, that's what the law becomes.
But in Michigan, I think all the states that have made it legal, the feds have just agreed to kind of turn a blind eye to it. And so it's guess it's a control drug that, [00:35:00] no one gives a damn about that kind of thing. So, that's that.
Semion Naidis: That's always the issue in the U S. You have The state laws and the federal laws that are not always going together and sometimes you have to get enough information to know what law you should obey. And
That's the same thing here when we ship medicines to the U.
Mike Koelzer: Samian, you mentioned
a patent attorney. you know, who was a patent attorney? Einstein. No, he wasn't a patent attorney. He just worked with
patents. Um, that's when he thought of all of
relativity stuff. He might've been too busy if he was an attorney doing he was just a patent officer or something doing it. So I Is there anything from a pharmacist point of view or a legal
point of view that you've felt challenged with in the past, either
[00:36:00] from. people asking you, are you,
just thinking, okay, how were we able to do this? And then you
found an answer to
Semion Naidis: so, from a pharmacy standpoint, I always think about how the patient can get The medicine safely. That's a long time to get the medicine from Israel to the U. S. So we always think about new technologies, ways to get it faster, straight to the patient. And in terms of law, we have the Israeli lawyers, we have the U.
So then you see PBM pharmacies, big pharmacies that just drop the package in front of the patient's door, even if it's Humira, Ozempic, whatever it is, and it just stays there. So We as, You know, medium or small business, Always think how we can give better service to the patient. We always find new technologies and new ways to do that, in a better way.
So let's say we always do the check-ins in the pharmacy. We put data loggers to see that this is controlled and we never go above 25 or Um, and we use ice and isolation packages. So, yeah, that's how we work. We just want the medicine to get safely to the patients.
Mike Koelzer: I have a professional acquaintance who was on [00:38:00] the show years ago and her son, Had a hell of a time getting his medicine, you know , the PBM system and so on. And then they forced her to get it through the mail and, you know, things would say there, no excursions past such and such degrees.
And she knew that it was sitting in the mail truck, you know, the
whole day at a hundred degrees or something like that. And so
that's interesting that you say that the rules from the
pharmacy to the Patient are not, they're not as strict maybe, or
not
Theo Symons: they're not regulated.
Mike Koelzer: not
regulate it. And so I can
vouch that's her life's mission right now is to get some regulation on
Semion Naidis: Because here in Israel. We do have regulation from manufacturer to warehouse, warehouse to pharmacy and pharmacy to patient. we have a
document of almost 40 [00:39:00] pages of how you control temperature for every medication and we have to obey.
Semion Naidis: And
Again, we are not always successful.
Sometimes there are issues, especially. with let's say, Arizona in summer, but even if the patient gets the medicine hot or there are any issues, we do send them a new one or find ways to get the medicine to them, better.
Mike Koelzer: And nowadays with all the tracking and things, I imagine there's even, I don't know, I mean, there's temperature things that have RFID radio things. I mean, there's all kinds of stuff you can control for, even at bigger distances.
Would you rather doing
what I do in Michigan or doing what you do in Israel in terms of, do you have onerous laws? Do you have things that don't make [00:40:00] sense? Do you have the pharmacist benefit managers? Is there such a thing? What is pharmacy like for you as a pharmacy in Israel versus someone like me in the States?
Semion Naidis: So in Israel, we have something that is called HMOs or Kupot Cholim. As you know, every patient, every citizen of Israel has to be included in one of the four kupat holim.
Theo Symons: That's
Semion Naidis: So this HMO is always negotiating prices with the manufacturer and then they get the best price. After they get the best price, you get even more discounts. If you have a specific indication, so let's say, I don't know, Ozampic is, is indicated for, diabetes, okay? if you are diabetic, you will get It for a very low price, If you. are not diabetic, have to take Wigovi, okay, which is, [00:41:00] which is of a higher cost, you.
have like the, the national insurance that is divided to, four big HMOs and they are the ones who negotiate prices.
Mike Koelzer: We pharmacists in the States, we have
a boatload of stuff that we can complain about if you
Do you think your list is longer? Or shorter, I'm not talking internationally. I'm talking about a pharmacy serving your neighborhood.
Theo Symons: an initial reaction, um, I think we have so many things that we, we know, small details that we could complain about. But ultimately our system is one where we basically never have to turn a they can't afford their medication. Uh, you know, there are so many mechanisms in place to help a patient at the point of care receive the treatment that they need.
And there's nothing more valuable than [00:42:00] that. It's an aspect of our healthcare system that I am thankful for. Every day that I learn more about the American healthcare system. I, I really, I literally thank God every single day that we have a system that that really, really feels like not always, you know, sometimes if you go to, um, if you go to the emergency room, you might still be waiting a really long time and you might have to, um, you know, you might have to pay like a nominal fee when you go there.
You, but when I say nominal fee, like it might be. $25, $30 to, for, for and that could last 10 hours. stay overnight, you don't, you don't pay for that. That's uh, invoice on, on the way out when you, when you leave the next morning.
a broad, on a broad, uh, on a broad perspective, I really believe that we have so much to be grateful for. Um, and we're really trying to pass on some of that goodness to [00:43:00] places because In the U S I could say, well, people can get what they need.
Mike Koelzer: It's like, no, they can't Mike. You just said you're not doing brand names at your store. You just said they had to go to the place that is forcing them away from your pharmacy and they're making them go to that PBM vertically integrated. That's freedom. That's, that's letting people get what they need.
They got to jump through the hoops and, and the rancid system. so that wears, so if I talk about job satisfaction, let's say of being either a pharmacy owner or pharmacist, that really wears on people. and a gaslighting, you know, it's like, yeah, you can get it.
No, no, you can't. I can't and maybe someone else can, but it's so many hoops to go that starts to wear on pharmacists in the U S
Theo Symons: know, you, you would say to them, well, I can't, I can't get it. The amount of independent pharmacies that have closed in the United States. [00:44:00] over like the age I, you know, I, I'm, I'm sure I'm not the one to break the news to you, but I, I but it looks like the idea, the, the, the business model of that local independent slowly drifting into, you know, either, either into these major corporations.
CVS, Walgreens, you know, the, the, the kind of the, the bigger names that are supplying, um, that are, that supplying pharmaceutical goods, or people moving over
Semion Naidis: If I speak from the standpoint of a pharmacist or a pharmacy owner. So I think in the U S you have these unfair things called reimbursements that, you know, the pharmacy gets the drug for 100 and then only gets back 50. Right. So.
Here in Israel, it never happens, okay? If you buy a drug for ten dollars, always get the ten dollars back, and you get another percentage for the service that you give to the [00:45:00] HMOs, okay? So if you, uh, a private pharmacy, You are able to have contracts with almost all the HMOs then patients, instead of going to the central HMO pharmacy and stand in lines, they can go to a private pharmacy and get the same drug for the price the private pharmacy will get reimbursed and also get a percentage.
For the dispensing fee or something like that. That's not always a big percentage. but at least you get reimbursed fully.
Mike Koelzer: boy, this is fun. Now, Theo, to bitch about this the third but I was telling Theo, the reason I was happy to talk to you guys is years ago, you would say, Oh, you know, how dare anybody try to break into the market. I took care of my own neighbors and all this kind stuff about three years ago.
We stopped selling brand names just for the reason you're talking about. We would order 10, 000 a night of medicine. [00:46:00] And a month later, we'd get 9, 000 back and I'm not talking about losing profit. I'm talking actually. We would only get back 90 percent of our cost.
And so in this great system where we're all supposed to pretend like everything's fine, uh, and not having any outside sources like yourself,
We've been a pharmacy for
Mike Koelzer: for 80 years on that corner, and I can't sell brand name medicine to my neighbors. And so it's like, piss on it. I'd rather have you guys involved than be giving that business to the pharmacies that the PBMs own and mailing it to the patients and hot trucks and. Not getting any pharmacist interaction. Screw So that's what I say, you know, we've talked here and I don't [00:47:00] know all the ins and outs of this. Maybe someone would scream, well, you can't, that's not legal. It's like, I don't care. I'm talking about the theory behind having a conversation like this, that it's, it's a big world with.
A lot more open competition now, mainly for the reason we're talking about here, because things don't take six weeks to get across the ocean. They take, you know, 0. 1 second or something like that. it's a, it's a market where everybody should have a chance to say, you don't have a corner on the You know, the PBMs don't have a corner on the market. There's others out there that want to serve people and can serve them. And I think it's worth the discussion to have.
Theo Symons: I think ultimately the central idea, the central theme of the discussion has to always come back to patient care. Who ultimately is providing the best quality of care for the patient? Quality of care can take a [00:48:00] variety of forms. It can mean providing the best version of the drug that they're asking for.
It can mean providing the best savings without compromising on quality. It can mean providing the consultation with a clinical professional that gives you the time of day. And ultimately, if that is the central theme of the conversation, I think we have a tremendous amount to offer. Um, I think it's, it's a lot of the time, particularly in, in, I've come to learn over the past year and a half, two years.
That there's an entire language, this entire set of jargon when it comes to PBMs, where I've, you know, at the beginning I would sit down in these meetings with these brokers and 50 percent of the words they would say, they would just confuse me. You know, it's just, it's a language that only they speak.
And it's, it's, it's a real barrier, um, not just [00:49:00] to others entering the market, but it's a barrier understanding what they're signing up for. Um, and a lot of the time it seems like they themselves don't necessarily have a complete grasp on the language that they're using to explain their services.
And I think part of transparency is being able to say, this is, this offer. This is what we can provide. It's as simple as that. That's what I'm telling you right now. And it doesn't have to go through, uh, the, the, the rebates PBMs or the, the, the, the, the, the variety of choose, that an employee can choose, uh, to, to, to get the best quality care for, for their workers.
Um, and I, I really think if we can, if we can get meant to be about, then, uh,
Semion Naidis: Yeah. I think it's that simple because, as Tio said, you go to the conversations and, and they thrown you all those terms and, and the end of the day, what we offer is just Go to the [00:50:00] employers platform, log in there, and you just see all the prices.
That's your price. That's all.
Mike Koelzer: Absolutely.
the price. That's the final price. I haven't dealt with brokers myself, really, but in the last couple years I've put together in my head, probably from help from But I've put together that you've got this face there and they come into the business 50 percent is plain English, 50 percent is jargon. And then the people don't really understand. So the brokers take them to lunch. Flash them a big smile and then they say, to we're getting X percent off of this. It's a good deal. Trust me,
and right there when someone says the percent off, what the hell does that mean? And so it's like, show me a site. That has prices on it, like, now I'm interested, you know, now I'm interested because you don't have this percent off [00:51:00] baloney.
Theo Symons: study to prove the exact point that you're talking about. I mentioned earlier that one of the areas we have, um, we had a lot of work to do in. is infertility or IVF treatments. And one of the really, uh, astounding things that I came across is when we were doing market research, just to understand what our standing was in the market, you know, where do we fall in pricing?
Are we a little bit under, undercutting the market? Where are we? And so I would reach out to local specialty pharmacies, and I would try and, you know, I would try to go on the website, find the pricing for the medication. And it, it just, it just isn't there. The only way that you could get a pricing for a particular medication is if you send them an order and ask for a quote.
And even then on basically every specialty pharmacy that we came across, there are conditions saying that the price can change. It's subject to, to whatever it might be subject to [00:52:00] that, that means they can add on, uh, or, or take away where they see fit. And I think the other point that you're bringing up is.
So long as it's a game of who can sell it to you for a dollar cheaper than the other guy, you're not going to make real change. Like I said, we have a model where we have a base price and as a company we add on between 10 and 20 percent. 20 percent being that upper boundary, 10 percent being a soft lower boundary.
There are some very, very expensive medications where we just sell it for the price that we have available to us because, um, it's already incredibly expensive and there's something not to abuse that we have. Um, but, but, but really trying to find prices of medications is such a challenge, particularly when it comes to specialty medication.
And I, I believe that transparency that we offer is something that should not be new. It should not be innovative. And yet that's been one of our biggest [00:53:00] selling points, which is This is what we set it for. That, that, like, like Semyon said,
Mike Koelzer: I don't have a wholesaler anymore because I don't do brand names, but we'd have these guys, they'd come in once a month, and I'd always play this game with them where I'd pick up the biggest bottle I could find in the pharmacy, heaviest one. And I'd, I'd set but set it down.
I would say, Bob, you know, Bob's my sales. I'd say, Bob, how much did I pay for that? They would never be able to tell you. You know, here you're doing millions of dollars with a wholesaler, and you gotta play these games of how much you know, this or that, and the refund, and well, if you hit this level, you the price. And then the wholesalers say, we have to play that game. Because the manufacturers play that game and the PBMs play that game.
And so maybe it's not fair to me just to pick on the wholesalers, but it's this whole baloney of discounts and percentages you know, [00:54:00] she used to buy shoes that were like three sizes too small and she couldn't even fit in them, but they were on sale, you know?
So she saved so much, you know, it's like, how do we get to that? Where we're not talking prices. I appreciate a company like yours. That's putting the price
Theo Symons: just jump in with one more comment. Um, and just, just As a, as a message to all healthcare providers across the United States, particularly pharmacy, you know, anyone that's operating something where they're, where they're marketing a drug, please publicize your prices. This is not something that we want to keep for ourselves.
This is not a standard that we want to be breaking the mold on. We encourage and we would applaud anyone. Any company that is brave takes that step and just says what, what they're paying, just be explicit and clear about what it is that you're selling, what it is that they're purchasing and what that costs.
It would make the [00:55:00] industry much
Mike Koelzer: a couple of, well,
There's a million different ways to market you know, and, and back in the fifties and things like that. And some people would market the price, you know, this is the lower price, but would talk about the fine. all that kind of stuff, but the difference there, there's different ways to lead to the market, to the, to the advertising, but the difference there is. You could find out within seconds, you know, well, how much or the expensive car or the expensive liquor, you know, whatever you led with uh, certain, uh, sophistication, but the them, you could find them, but in the healthcare in the U S. You can't, you can't find anything,
Semion Naidis: And you also have to understand that we are talking about the same product. We're not talking about generic stuff That's exactly the same product. Maybe the package can be, one side English, one side Hebrew, but it's still the same [00:56:00] product. people know our prices, we show them the prices for the same product.
I think the U. S. market can sell their prices for the same product. and I also think, that in terms of, quality, , at the end of the day, When you go to the US and there is a shortage of something the FDA allows, pharmacies to compound medications that are not FDA approved, not because of the package of the medication, but because that's not the brand name.
Okay? That's not the brand name. no one checked. the pharmacokinetics, the pharmacodynamics of that thing, even if that's. the same active ingredient. We still see sublingual semaglutide, some sublingual tripeptide, which no one checked the efficiency of that stuff, And we still [00:57:00] see that on the market and the whole model is approved by the FDA, even if the drug is not approved by the FDA. But such a model is approved by the FDA. If people really can get the same brand name medication from another country, from international pharmacy, that's huge because they don't have to use this compounded stuff that no one knows what's inside.
Mike Koelzer: What, um, Are there any roadblocks that you say, ah, that you'd think of that weren't there, maybe we could open up a bottleneck.
What bottlenecks
Theo Symons: So one of the, uh, One of the biggest bottlenecks. is trust for our company.
Uh, always,you know, ordering something overseas, particularly when it comes to medication, certainly from the American mindset where, you know, like you said, every,America, right? What, what, what comes from outside of America? Um, and I just understand the level of regulation, [00:58:00] um, and the standards enforced by the health ministry in Israel.
Uh, they would be far more at ease, uh, about, about working with us and about utilizing our solution
Semion Naidis: One thing that I think is good, in the U S system is that you always get the medications first. Okay. So if we have like new weight loss medications, you will first see it in the U S and only after, you know, half a year, maybe a year, you will see it in other countries.
So let's say Manjaro. Okay. We just got Manjaro last week. You have Manjaro in the U S for like two years or something like that. want two years? You get the new technologies first, but you always get the higher prices and that's the period of time that, uh, that they have, that the manufacturer, gains, the most of money.
[00:59:00] When it's in the U. S. and then they get it to the other countries where their profits are much
lower.
Guys, what's the best way for someone to reach you?
Theo Symons: on the show.
And
if anyone wants to find us,
They can Uh, either search my name, Theo Simons, THE SYMONS, or my partner Semion, S E I O N space N A I D I S.
Mike Koelzer: well, golly guys, thanks for joining
guys. And as I said before, promoting you guys. I don't, I don't know what to promote here. I just. Have conversations and we tell stories and things, but I tell you
even through today,
Mike Koelzer: three
years ago
when I was
not able to sell a brand name to a customer that I've been serving for 75 years.
And if I can't do it , screw it. I'll at least have the conversation. So I appreciate you guys being here. [01:00:00] I know you've got a lot to do. So, so thanks for your
Semion Naidis: Thanks Mike. It was a pleasure talking to you
You've been listening to the Business of Pharmacy podcast with me, your host, Mike Kelser. Please subscribe for all future episodes.
