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How Pharmacy Benefit Managers Are Harming Patients

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The state of New York’s prescription drug system is broken. It’s hurting patients and smaller pharmacies, and I believe the biggest problem is Pharmacy Benefit Managers (PBMs).

PBMs are a group of middlemen who have a lot of influence, from what we pay for medication to what our doctors are allowed to prescribe us. They were created to process drug claims for insurers, including Medicaid, and their plan sponsors. Over a period of time, they have gained power that goes far beyond the original mandate.

They are supposed to negotiate with manufacturers on drug prices, determine what drugs the insurance plans will cover, charge the insurers money to cover patient drug claims, and decide how much to reimburse pharmacies for dispensing medications to patients. The top three are CareMark, Express Scripts and Optum.

While very sick and elderly patients are dependent on medications, PBMs impact all of us. They keep the costs high for drugs and control which ones your doctors can prescribe to you.

I have personally had to deal with CareMark several times over the years. The first time was when they failed to send me my Crohn’s medication through the mail. When I called, their excuse was they never received the script from my GI’s office. I called the office and the secretary told me she sent it four times. I contacted CareMark again and informed them it was sent, only to be told they still don’t have it. So I was without my medication. I wound up calling my old pharmacist and he was able to get what I needed within 24 hours. Needless to say, I stopped mail order because I realized the company doesn’t care about its customers, only the bottom line.

Mom and pop pharmacies don’t have a say in patient payments, plus get back their costs through reimbursements they get from PBMs. They decide how much gets reimbursed and can change the rates anytime they want without warning.  These rates have declined steadily over time.

I’ve been going to the same pharmacy for several years because the staff is personable, my pharmacist knows my medical history very thoroughly, and I can contact them anytime if I have questions. Even though it’s a smaller business, I know I’m getting quality care and service. If they were to go out of business due to lesser reimbursements down the road, I’d have no choice but to go mail order which is unsafe for someone like myself who is very high risk. You can’t talk to a pharmacist face to face, they don’t know their customers as thoroughly as the smaller pharmacies do, plus there’s a higher chance of the order coming crushed which causes problems for the customer when it needs to be taken as a whole. Then they have to wait another seven to 14 days to get the correct package.

As a “professional patient” speaking on behalf of others like myself, we need new regulations to protect us and neighborhood pharmacies. PBMs don’t provide any healthcare services. They are the only unregulated entity that has no accountability. The state should follow what other states have done and do an audit accounting for every dollar that was paid to these middlemen.

PBMs have no clue what I’ve been through. It’s wrong for them to assume what treatment is best for my care. They haven’t walked in my shoes or seen what I’ve gone through. Do they care if their customer wound up in the hospital because they denied the medication they needed to get their symptoms under control?

What will it take for these issues to be rectified? Another patient not getting the proper care, or worse?

Getty image by Okskaz.

Originally published: March 18, 2019
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