Pharmacy Benefit Manager Resources
Pharmacy Benefit Managers, or PBMs, are largely unrecognized by most employees and even many employers, but they have a tremendous impact on U.S. health care decision-making.
For example, the top three PBMs, Express Scripts, CVS Caremark, and OptumRx, control 80% of the market and are vertically integrated with insurance companies and pharmacies. This vertical integration and market share allows the large PBMs to steer patients to affiliated entities exercise undue market leverage and generate outsized profits for themselves, while community pharmacies continue to close and pharmacy deserts grow.
PBMs determine which pharmacies will be included in a prescription drug plan's network and how much said pharmacies will be paid for their services. Some entice plan sponsors to require plan beneficiaries to use a mail order pharmacy – often one owned and operated by the PBM – for certain medications. They also determine which medications will be covered by the plan or plan formulary, and drug manufacturers often pay “rebates” to PBMs to get their drugs onto those formularies. While their role goes largely unnoticed, the nontransparent nature of the traditional PBM business model can add hidden costs and lead to higher prices.
These resources can help you fight back and promote reforms that level the playing field for community pharmacies and improve patient access to medications.
Legislative One Pagers
PBM Resources
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Vertical Business Relationships within the U.S. Drug Channel, Source: Drug Channels
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