What is a PBM?
Pharmacy Benefit Managers, or PBMs, are large corporate middlemen in the pharmacy supply chain that you may not recognize. However, these obscure corporations play an outsized role on how much you pay for your medications and your health care outcomes.
PBMs determine which pharmacies you can visit by determining your coverage network. In fact, your preferred pharmacy may be excluded from the network simply because the PBM chooses not to include them, even if your pharmacy would be a willing participant. Depending on where you live, if your local pharmacy is excluded, you could be forced to either travel a great distance to utilize the PBM’s “network” pharmacy or pay much higher costs to use your local pharmacy. Neither option is fair!
While the PBM limits your pharmacy options, it also sets the prices it pays to your pharmacy for filling your prescription—often paying the pharmacy less than the pharmacy’s cost for acquiring the medication. This can have devastating consequences for you if your pharmacy is forced to shut its doors because they can’t continue to absorb the financial losses.
You may even lose access to brick-and-mortar pharmacies altogether as PBMs entice employers and other sponsors to require the use of a mail order pharmacy – often the one owned and operated by the PBM – for certain medications. This deprives you of access to face-to-face consultations with your pharmacist, and could even lead to you receiving the wrong medication or medications that have been damaged by sitting out in extreme weather conditions. This can lead to harmful outcomes for you, and result in you paying more to have the PBM correct its mistake.
Not only do PBMs control where you obtain your medication, they also determine what medications you can take by determining what medications they will cover. This decision is often based on the size of the rebate that the PBM extracts from drug manufacturers. Keep in mind, the covered medication may not be the medication your doctor thinks will be most effective, and you and your doctor may have to jump through several hoops to get the medication that is most effective for you.
And those rebates? While you may think your PBM uses the rebates to lower prices for you and your plan, unfortunately, that is not often the case. While rebates may enrich the PBM and their corporate shareholders, your cost is often determined by the list price of the medication, not the post-rebate, discounted price. This inflates your out-of-pocket costs. As PBM rebates continue to grow, so do your out-of-pocket costs.
PBMs determine which pharmacies you can visit by determining your coverage network. In fact, your preferred pharmacy may be excluded from the network simply because the PBM chooses not to include them, even if your pharmacy would be a willing participant. Depending on where you live, if your local pharmacy is excluded, you could be forced to either travel a great distance to utilize the PBM’s “network” pharmacy or pay much higher costs to use your local pharmacy. Neither option is fair!
While the PBM limits your pharmacy options, it also sets the prices it pays to your pharmacy for filling your prescription—often paying the pharmacy less than the pharmacy’s cost for acquiring the medication. This can have devastating consequences for you if your pharmacy is forced to shut its doors because they can’t continue to absorb the financial losses.
You may even lose access to brick-and-mortar pharmacies altogether as PBMs entice employers and other sponsors to require the use of a mail order pharmacy – often the one owned and operated by the PBM – for certain medications. This deprives you of access to face-to-face consultations with your pharmacist, and could even lead to you receiving the wrong medication or medications that have been damaged by sitting out in extreme weather conditions. This can lead to harmful outcomes for you, and result in you paying more to have the PBM correct its mistake.
Not only do PBMs control where you obtain your medication, they also determine what medications you can take by determining what medications they will cover. This decision is often based on the size of the rebate that the PBM extracts from drug manufacturers. Keep in mind, the covered medication may not be the medication your doctor thinks will be most effective, and you and your doctor may have to jump through several hoops to get the medication that is most effective for you.
And those rebates? While you may think your PBM uses the rebates to lower prices for you and your plan, unfortunately, that is not often the case. While rebates may enrich the PBM and their corporate shareholders, your cost is often determined by the list price of the medication, not the post-rebate, discounted price. This inflates your out-of-pocket costs. As PBM rebates continue to grow, so do your out-of-pocket costs.