Why We Need A Better Regulated Pharmacy Benefit Manager (PBM)?

Prescription drug spending is a billion-dollar problem for the payer industry. While pharmacy benefit managers (PBMs) are often a positive way for payers to manage prescription drug benefits for their members, savings for payers can be limited because of complex or one-sided contracts that benefit PBMs more than their partners.

The Pharmaceutical Care Management Association (PCMA) represents managed care pharmacies, PBMs, and their healthcare partners in pharmaceutical care. PCMA opposes efforts to regulate PBMs. They believe that various services performed by PBMs (e.g. Internet activities, Mail service pharmacy licensure, Drug utilization review, Claims management) are already appropriately regulated under existing federal and state laws. According to PCMA, further regulation would unnecessarily interfere with The PBMs’ unique ability to link patients, physicians, and pharmacists it would also increase operating costs for PBMs and reduce their ability to pass on cost savings to consumers. Determining whether a PBM partnership is right for a payer’s needs requires the health plan to weigh up the pros and cons of contracting with a middleman. The Pharmaceutical Care Management Association (PCMA) believes that PBMs benefit payers through annual drug savings, promotion of generic drugs and cheaper prescription alternatives. They can also help payers facilitate enhanced care delivery.

The Reason That We Need A Better Regulated Pharmacy Benefit Manager Includes:

  • This Is A Transparency Bill That Should Keep Pharmacists Better Informed About How PBMs Determine Maximum Allowable Costs (MACs).
  • Strengthens Existing MAC Law Enacted In 2013, Attempting To Create Accountability In Prescription Drug Pricing.
  • This Law Addresses PBM Registration As A Third Party Administrator And Will Ideally Develop A More Structured Pathway For PBM Enforcement And Oversight.
  • This Law Creates A Bill Of Rights To Be Followed For Any Entity Conducting An Audit Of A Pharmacy.
  • Requires PBMs To Itemize By Individual Claim The Amount Actually Paid To The Pharmacy Or Pharmacist, And An Identifier Of The Pharmacist Services.
  • This Act Preserves The Professional Independence Of A Pharmacist / Pharmacy. Additionally This Act Limits The Retaliatory Actions That A PBM Can Engage In Vis A Vis Pharmacy.
  • Regulates How Drugs Can Be Put On The MAC List As Well As Requires The MAC Lists Be Made Available To Pharmacies. The Act Also Requires That Necessary Updates Be Performed On The MAC List Every 7 Days. It Also Creates An Appeals Process For Pharmacies To Dispute MAC Price Billing With PBMs.

PBMs are a type of Middleman Company hired by insurers to negotiate pharmaceutical prices with drug manufacturers and handle insurers pharmacy claims. When a patient with insurance fills a prescription at a pharmacy, the PBM reimburses the pharmacy on the insurer’s behalf. That gives PBMs enormous leverage over the opaque world of drug pricing and broad power in the health care system generally. The nation’s three leading PBMs — CVS Caremark, Express Scripts and OptumRx — manage prescriptions for 180 million Americans.

Payers that have the populations and resources to contract PBMs may be able to curb unnecessary prescription drug spending, and payers should always review the details of PBM compensation before entering into agreements. But payers that may require an expert partner to help save prescription drug costs stand to benefit from a PBM contract.