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PBM & Insurance Practice

While patients and their families often struggle to access the medicines they need to treat their conditions, insurance industry middlemen, known as Pharmacy Benefit Managers (PBMs), to institute harmful policies and practices that exacerbate those challenges for the sake of greater profits. Amid ongoing discussions about how to improve our health care system, policymakers must address how PBM practices impact access, affordability, and outcomes for patients with complex and chronic conditions.

 

While PBMs were initially tasked with processing pharmacy claims, their role and influence within the health care system and prescription drug supply chain has evolved and expanded over time.  Despite what we know about PBMs today, a lack of necessary oversight and regulation has allowed these industry middlemen to create loopholes through which they often take advantage of patients, institute treatment barriers at almost every step in a patient’s journey and increase their profits to the detriment of vulnerable populations.

  • Policies are Shifting Greater Cost Burden onto Patients. Between 2008 and 2018, deductibles for covered workers increased by an average of 212%, signaling that health plans are shifting the cost burden onto patients.
  • Patients Abandon Their Medications When Costs Go Up.When out-of-pocket treatment costs reach or exceed $250, 70% of patients abandon their prescriptions at the pharmacy counter. In 2020 alone, patients starting a new therapy abandoned 55 million prescriptions at pharmacies.
  • The COVID-19 Pandemic Has Exacerbated Access and Affordability Challenges.Between April 2020 and April 2021, 46% of surveyed patients said they or someone in their immediate household had not been able to afford the out-of-pocket costs for a prescription treatment.

If PBMs continue to have the ability to implement discriminatory practices and fail to share rebates with patients, they will be partially responsible for millions of patients foregoing their treatment regimens.