1 apr 2022 anni - PBMs use their sizable patient networks to negotiate lower reimbursement rates with pharmacies and discounts with drug makers.

Descrizione:

Pharmacy benefit managers (PBMs) are key players in the complex prescription drug supply chain. They act as middlemen, responsible for developing and maintaining formularies and other clinical management programs, negotiating contracts with pharmacies and pharmaceutical manufacturers and processing prescription drug claims for insurance companies and corporations.

PBMs use their sizable patient networks to negotiate lower reimbursement rates with pharmacies and discounts with drug makers.1 Today, average discounts for brand drugs range from 15-21 percent off of market price and average discounts for generics range from 72-82 percent.2,3 The original idea was that the PBM would pass those savings back to their health plan sponsors, and thus, ultimately, to patients.4

PBMs first stirred controversy in the 1990s, when pharmaceutical companies began to acquire them. The Federal Trade Commission (FTC) denied mergers between several pharmaceutical companies and PBMs because of potential conflicts of interest. The FTC believed that these mergers would enable drug manufacturers to coordinate pricing policies, understand their competitors’ pricing information, and favor their own drugs over their competitors’.5 Due to FTC concerns, manufacturers later sold these joint entities, which led to PBMs adopting a strategy of becoming large stand-alone PBMs or PBM-pharmacy chains.6 Today, about 80 percent of the prescription drug benefits market is controlled by just three PBMs--Express Scripts, CVS-Caremark, and OptumRx.7

Given the client-centered origins of the PBM role, it is somewhat surprising that pharmacy benefit managers are under fire for not acting in their clients’ best interest. PBM’s have come under scrutiny for anti-competitive behavior that results in higher costs to payers and consumers and may limit access to certain drugs. In fact, the ways in which PBMs make money has the potential for a conflict of interest vis-a-vis the payers who hire them.

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