Prescription Drugs - Medicine & Money

The truth about prescription drug costs.

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Patients

Most people don’t even know what a pharmacy benefit manager is. Turn your insurance card over and you’ll likely see the name of an organization that approves, or disapproves, every prescription your doctor orders for you. A PBM is a pharmacy benefit manager, an entity that stands between you and the medicines your doctor orders, all in the name of saving you and your employer money.

In reality, a pharmacy benefit manager is another “pocket” to stuff your healthcare money into. A pharmacy benefit manager began as a claims administrator, but now pharmacy benefit managers are just money-making machines.

There are documented examples of PBMs causing drug dangers, such as inappropriate substitutions, converting temperature-sensitive medicines to mail order, and, in one notorious instance, repackaging returned drugs and sending them to unsuspecting patients.

How do you like this scenario:
Your doctor prescribes a medicine. But the pharmacy benefit manager says “no, that’s a new medicine and it’s more expensive than this older drug.” Your doctor responds “I want my patient to have this particular drug because it has a specific ingredient or combination of ingredients that I believe is better for my patient.” And the pharmacy benefit manager says “try this old drug first. If it really doesn’t work, well, we’ll think about letting you try the one your doctor prescribed.”

Another problem scenario:
Your physician prescribes a drug at a certain dosage. But your pharmacy benefit manager only approves a different dosage that is more than you need. So you’re in the position of splitting your pills, leaving crumbs behind and hoping you’re getting the adequate amount.

Not pretty pictures, are they? But that’s happening. Maybe you’ve already experienced it yourself or for one of your family members.

Before you get angry at your employer, consider they may not even know what the pharmacy benefit manager is doing. They just know that the insurance plan promised to save them some money and get drugs at a better price. They may not know how the pharmacy benefit manager is “saving” that money. That’s why there is a movement for “transparency.”

Transparency as it relates to pharmacy benefit managers is the requirement that the pharmacy benefit manager fully disclose to employers how they operate, what their agreements are with pharmaceutical manufacturers, and whether they limit brand or generic drugs based on those contracts.

As a patient/employee, you can bring this situation to the attention of your employer. Give them a copy of the 10 Questions Benefit Managers Should Ask Their pharmacy benefit manager.

Don’t forget, you’re a VOTER! Talk to your state legislators. Insist that pharmacy benefit managers conduct business in an open and honest manner.