2/20/2018 by Share Your Story

Pharmacy Benefit Managers restrict access for patients living with a chronic disease

Pharmacy Benefit Managers tell insurance companies which drugs to cover and restrict access for patients living with a chronic disease.


As most of you know, living with a chronic disease is challenging at best and debilitating at worst. Patients shouldn’t have to deal with the additional stress of figuring out how to pay for their medicines. But the reality is, many are.

By now you’ve probably read our blogs about Pharmacy Benefit Managers (PBMs) and how they are coming under deeper scrutiny in legislatures across the country. And for good reason. Pharmacy Benefit Managers work with insurers to determine the price you have to pay. First, they negotiate steep discounts from drug manufacturers. They then tell insurance companies which drugs to cover. PBMs also sign contracts with pharmacists and tell them what to charge. What PBMs and insurers don’t do is pass along those savings to consumers. In fact, insurers set their co-pays based on the list price of the drug, not the discounted price.

What can you do about it? There are several things.

First, always ask your pharmacist to tell you what the cost of the drug would be if you didn’t go through your insurer. It sounds counterintuitive, but often it’s cheaper that way. Unfortunately, the contracts that pharmacists sign with the PBMs include a gag order, so they are not allowed to tell you automatically that it might be cheaper to pay on your own. The onus is on you to ask.

Some states have enacted laws the prohibit these gag clauses. Others have legislation pending to do the same.

PBMs work with insurers in a number of complicated ways. And they’re not regulated, unlike the rest of the healthcare delivery system. As lawmakers look at ways to contain the cost of drugs they need to investigate the cozy relationship between PBMs and insurance companies. You can help make that happen.

If you live in Maine, click on this link: https://patientsrising.org/maine/

If you live in Vermont, click on this link: https://patientsrising.org/vermont/

Help us, help protect patients.


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