I am a pharmacist. I am a pharmacy owner. I am an employer. And for six months of my life, I was also a cancer patient.
While I already knew of the problems with PBMs and healthcare, that unique vantage point confirmed something Kansans deserve to know: when it comes to prescription drugs, we do not have a free market. We have a monopoly — and it is costing patients, employers, and taxpayers far more than they realize.
Pharmacy benefit managers, or PBMs, were originally created to help administer prescription drug benefits. They were to process claims. Today, through consolidation and vertical integration, they have become something very different.
A handful of PBMs now control which drugs are covered, where patients are allowed to fill prescriptions, and how much pharmacies are paid — while owning their own “specialty” and mail-order pharmacies. They pay non-affiliated pharmacies less than they pay their own. They make billions on “spread” pricing — where they pay pharmacies they don’t own one price, and bill the payer (employers and taxpayers) a higher price and keep the “spread.” Often hundreds or even thousands of dollars.
They hide this from the payers. In fact, many of the “take it or leave contracts” offered to the local pharmacy actually prohibit the pharmacy from sharing with the payers what the pharmacy gets paid. Where else can the purchaser of a product not be allowed to talk to the actual seller? They also hold manufacturer rebates, intended to lower costs to plan sponsors, in overseas companies, and send only a portion back to their parent company — but tell the plan sponsors (employers and taxpayers) they are giving all the rebates back! Sound like the Mafia?
That is not competition. It is control. When three companies control over 80% of the market, and with no regulation, they capitalize. They monopolize.
PBMs use that power to systematically underpay independent pharmacies, driving many out of business. When local pharmacies disappear, PBMs steer more patients into their own affiliated operations. They claim this saves money. My experience proves otherwise. It is a conflict of interest and increases costs!
Six years ago, I was diagnosed with cancer. My doctors prescribed a treatment plan that included radiation, IV chemotherapy, and an oral chemotherapy drug called capecitabine.
At the time, as owner of AuBurn Pharmacy, we were insured through Blue Cross Blue Shield, with Optum serving as the PBM. My pharmacy had the medication on the shelf. We were contracted with Optum. As the patient, the pharmacist and the plan sponsor — the person responsible for providing health insurance to my employees – I attempted to fill my prescription at my own pharmacy.
My claim was denied.
I was required to use a PBM-designated “specialty” pharmacy instead.
Who gets go decide which medications are “special?” PBMs do. They define “specialty” drugs as those with high cost and more complex therapy. They then require them to go through their own “specialty” and mail order pharmacies. Even when stocked at the local pharmacy — including mine.
The result was staggering.
If my prescription had been filled locally, the total cost for six months of therapy including the drug and reasonable professional fees would have been approximately $2,840. That’s $2,600 for the cost of the medication and a total of $240 markup.
Instead, when forced through the PBM’s specialty pharmacy, my health plan was billed nearly $50,000, but due to “plan savings,” only paid $15,000. Touting a SAVINGS of $35,000. Who would ever know the difference? I did. Smoke and mirrors.
That is more than a $12,400 increase for the exact same medication — a markup of over 5,000 percent. All profit. One medication.
