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Not so fast, PBMs: You aren’t fooling consumers

Updated: 7 days ago


A recent op-ed, “It’s Time for Facts in the PBM Debate” by the president of one of the nation’s largest pharmacy benefit managers (PBMs), is at odds with the reality of what consumers are facing when we go to the pharmacy.


In his commentary, David Joyner paints a rosy picture of how the largest PBMs lower drug prices. Meanwhile, consumers across the country are being hit with higher out-of-pocket costs and a lack of understanding about what goes into the costs for their medicines. This opaque system results in consumers running into several issues trying to access more affordable drug options.


The PBMs aren’t fooling anyone.


In Joyner’s own company, a whistleblower brought suit over the PBM’s scheme to keep lower-cost generics off its formularies for Medicare beneficiaries, pushing seniors to more expensive drugs (for which the PBM had negotiated higher profits for itself). The whistleblower said she was told by company executives that the financial benefits of this manipulation outweighed the possibility of getting caught.


More recently, community pharmacies in Iowa filed a lawsuit against CVS Health and its Caremark PBM claiming that they violated antitrust laws and illegally collected fees from pharmacies filling Medicare prescriptions. We’ve seen this behavior often force trusted, and long-established local pharmacies out of business.


What’s most concerning is that such questionable PBM behavior can have tragic results beyond pharmacy closures. In Wisconsin earlier this year, a young man with severe asthma died after he was informed at the pharmacy that his inhaler was no longer covered by insurance and he couldn’t afford the hefty out-of-pocket cost.


We can’t let this happen to another person. Consumers deserve more transparency. They deserve accountability in this middlemen PBM system. Most of all, we all deserve better than to be inundated with large PBM falsehoods.


Even as these mega-PBMs assure us that they are patient advocates, they are fighting tooth and nail in Congress and state legislatures to block measures that would take the necessary steps to ensure that consumers – and not the PBMs themselves – actually benefit.


Those are the facts in the big PBM debate.


Author: Robin Strongin, Senior Director of Health Policy

2 comments

2 Comments


The PBMs are still doing, to this day, everything we accuse them of. They still claw back money from us and/or the patients for doing nothing, they still prefer expensive brand name drugs to line their pockets with rebates. Just this week, Optum preferred brand name Uceris tablets ($1700 cost) and willingly "paid" most of it (>$1400), leaving the patient's copay at just under $300. The problem with this, is that the generic is not terribly much more out of pocket than $300 even with no insurance. So Optum could've paid for 100% of the generic and it would have been much cheaper for Optum and obviously for the patient as well. Instead, the benefit for the patient is tha…


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How can ANYBODY, even if they are being paid off, let this go on and on and on?! It is beyond despicable! People are dying bc they cannot afford their medications in The United States of America. The elderly on "Medicare-D" are especially hit hard- they are on fixed incomes, drug prices jacked up, and expensive, life-saving prescriptions are not covered, so they go without- I see it EVERY SINGLE DAY.

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