156:. Pharmacies and insurance companies are often prohibited by the PBM from discussing costs and reimbursements. This leads to lack of transparency. Therefore, states are often unaware of how much money they lose due to spread pricing, and the extent to which drug rebates are passed on to enrollees of Medicare plans. In response, states like Ohio, West Virginia, and Louisiana have taken action to regulate PBMs within their Medicaid programs. For instance, they have created new contracts that require all discounts and rebates to be reported to the states. In return, Medicaid pays PBMs a flat administrative fee.
179:"clawback". Consumers can choose to buy the drug in cash, but in their contracts with pharmacies, PBMs would forbid pharmacists from telling consumers about the possibility of buying their medication for a cheaper price without an insurance claim, unless consumers directly ask about it. Since 2017, six states have passed legislation making such "gag clauses" illegal. This has recently been followed by a federal bans on gag orders for private insurance effective Oct 2018, and for Medicare effective Jan 2020.
171:
several "tiers" of preference, with low tiers being assigned a higher copay to incentivize consumers to buy drugs on a preferred tier. Drugs which do not appear on the formulary at all mean consumers must pay the full list price. To get drugs listed on the formulary, manufacturers are usually required to pay the PBM a manufacturer's rebate, which lowers the net price of the drug, while keeping the list price the same.
2055:
235:
In 2007, when CVS acquired
Caremark, the function of PBMs changed "from simply processing prescription transactions to managing the pharmacy benefit for health plans", negotiating "drug discounts with pharmaceutical manufacturers", and providing "drug utilization reviews and disease management". PBMs
170:
PBMs advise their clients on ways to "structure drug benefits" and offer complex selections at a variety of price rates from which clients choose. This happens by constructing a "formulary" or list of specific drugs that will be covered by the healthcare plan. The formulary is usually divided into
147:
of enrollees through their client health plans, enabling plan sponsors and individuals to obtain lower prices for their prescription drugs. PBMs negotiate price discounts from retail pharmacies, rebates from pharmaceutical manufacturers, and mail-service pharmacies which home-deliver prescriptions
151:
Pharmacy benefit management companies can make revenue in several ways. First, they collect administrative and service fees from the original insurance plan. They can also collect rebates from the manufacturer. Traditional PBMs do not disclose the negotiated net price of the prescription drugs,
329:
was the nation's second-largest PBM. Caremark Rx was subject to a class action lawsuit in
Tennessee, which alleged that Caremark kept discounts from drug manufacturers instead of sharing them with member benefit plans, secretly negotiated rebates for drugs and kept the money, and provided plan
1645:"Public Inspection: Fraud and Abuse: Removal of Safe Harbor Protection for Rebates Involving Prescription Pharmaceuticals and Creation of New Safe Harbor Protection for Certain Point-of-Sale Reductions in Price on Prescription Pharmaceuticals and Certain Pharmacy Benefit Manager Service Fees"
178:
which is based on the public list price, and not the confidential net price. Around a quarter of the time, the cost of the insurance copayment on the list price is more than the entire price of the drug bought directly in cash. The PBM can then pocket the difference, in a practice known as a
236:
also created a formulary to encourage or even require "health plan participants to use preferred formulary products to treat their conditions". In 2012, Express
Scripts and CVS Caremark transitioned from using tiered formularies, to those that excluded drugs from their formulary.
244:
As of 2013, in the United States, a majority of the large managed prescription drug benefit expenditures were conducted by about 60 PBMs. Few PBMs are independently owned and operated. PBM's operate inside of integrated healthcare systems (e.g.,
152:
allowing them to resell drugs at a public list price (also known as a sticker price) which is higher than the net price they negotiate with the manufacturer. This practice is known as "spread pricing". The industry argues that savings are
400:
On
January 31, 2019, Health and Human Services released a proposed rule to remove Anti-kickback Statute, safe harbor protections for PBMs and other plan sponsors, that previously allowed PBMs to seek rebates from drug manufacturers.
308:
regarding the potential use of tactics that "can allow drugmakers to work around reimbursement restrictions" from
Express Scripts and other insurers. These reviews resulted from investigations into "questionable practices" at
2079:
283:
As of 2022, Caremark Rx, Express
Scripts, OptumRx, Humana, Prime Therapeutics, and MedImpact Healthcare Systems were the six largest public PBMs that control 95% of the market, while the top three control 80% of the market.
296:
for $ 29.1 billion and became "a powerhouse in managing prescription drug benefits". As of 2015, Express
Scripts Holding Company was the largest pharmacy benefit management organization in the United States.
378:
PBMs may pose conflicts of interest, and that PBMs' health plan sponsors "face considerable obstacles in...determin compliance with PBM contracts including direct and indirect PBM compensation contract terms".
1551:
1644:
211:(PCS, later AdvancePCS) invented the plastic benefit card. By the "1970s, serve as fiscal intermediaries by adjudicating prescription drug claims by paper and then, in the 1980s, electronically".
407:
said in April 2019 that they were as “clear a middleman rip-off as you are going to find”, because they make more money when they pick a higher priced drug over a lower priced drug.
391:
979:
357:
In 2004, litigation added to the uncertainty about PBM practices. In 2015, there were seven lawsuits against PBMs involving fraud, deception, or antitrust claims.
1002:
397:
stated regarding PBMs, "Everybody wins when list prices rise, except for the patient. It’s rather a startling and perverse system that has evolved over time."
330:
members with more expensive drugs when less expensive alternatives were available. CVS Caremark paid $ 20 million to three states over fraud allegations.
425:, consolidation and other factors. It looks likely to sue as soon as August 2024. As of July 2024, states that have already filed suits against PBMs include
1693:
1363:
850:
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1327:
464:
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1442:
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copies of branded drugs from big pharmaceutical companies" from 1992 through 2002, they had "quietly moved" into marketing expensive brand name drugs.
622:
140:
53:
2038:
1795:
827:
354:
James
Sheehan of the federal Justice Department, and their effectiveness in reducing prescription costs and saving clients money was questioned.
174:
The complex pricing structure of the formulary can have unexpected consequences. When filing an insurance claim, patients usually are charged an
1121:
708:
1213:
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released an interim report on its 2-year investigation into pharmacy benefit managers, many of which it accuses of raising drug prices due to
1027:
1509:
215:
1099:
360:
State legislatures have been using "transparency," "fiduciary," and "disclosure" provisions to improve the business practices of PBMs.
1735:
1252:
Shepherd, Joanna (July 2013). "Is More
Information Always Better? Mandatory Disclosure Regulations in the Prescription Drug Market".
75:
As of 2016, PBMs managed pharmacy benefits for 266 million
Americans. In 2017, the largest PBMs had higher revenue than the largest
1669:
751:
2013:
1416:
367:
study found negotiated prices at mail order pharmacy to be up to 83% higher than the negotiated prices at community pharmacies.
2033:
219:
80:
305:
250:
61:
727:
1003:"Prohibiting PBM "Gag Clauses" that Restrict Pharmacists from Disclosing Price Options Recent State Legislation 2017-2018"
102:
This consolidation and concentration has led to lawsuits and bipartisan criticism for unfair business practices. By 2024,
1618:
76:
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1009:
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956:
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released its first article in a series critiquing pharmacy benefit managers for artificially raising drug prices.
83:. However, in 2016 there were fewer than 30 major PBM companies in this category in the US, and three major PBMs (
124:
41:
228:
In August 2002, the Wall Street Journal wrote that while PBMs had "steered doctors to cheaper drugs, especially
115:, and many states Attorneys General have accused pharmacy benefit managers of unfairly raising prices on drugs.
2003:
1844:
1526:
674:
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112:
784:
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1985:
351:
310:
144:
534:
1728:
1390:
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293:
214:
By the late 1980s, PBMs had become a major force "as health care and prescription costs were escalating".
1960:
1945:
375:
339:
2028:
1965:
1859:
1768:
886:
828:"The Prescription Drug Landscape, ExploredA look at retail pharmaceutical spending from 2012 to 2016"
422:
314:
165:
199:, and many states Attorneys General argue pharmacy benefit managers unfairly raise prices on drugs.
1975:
1907:
1890:
1869:
1790:
1763:
56:, and state government employee plans. PBMs operate inside of integrated healthcare systems (e.g.,
1080:
1057:
1970:
1933:
1902:
872:
732:
600:
509:"Big pharmacies are dismantling the industry that keeps US drug costs even sort-of under control"
277:
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103:
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69:
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wrote that PBMs cause an inflation in drug costs, especially within the area of diabetes drugs.
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57:
45:
567:
Schulman, Kevin A.; Richman, Barak D. (2018). "The Evolving Pharmaceutical Benefits Market".
2018:
1993:
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1938:
1912:
1825:
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17:
709:"FTC report slams pharmacy 'middlemen' for seemingly driving up prices, limiting access"
1998:
1897:
1417:"Exclusive: Beyond Valeant, U.S. payers scrutinize other drugmaker ties to pharmacies"
641:
2073:
1854:
1849:
1527:"The State of Competition in the Pharmacy Benefits Manager and Pharmacy Marketplaces"
1230:
802:
851:"Bipartisan leaders of Senate panel call for federal probe of PBMs' pricing methods"
1811:
604:
254:
229:
153:
88:
65:
1532:. House Judiciary Subcommittee on Regulatory Reform, Commercial, and Antitrust Law
902:
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1758:
1694:
Pharmacy benefit managers: The middlemen who decide what you pay for medications
933:
326:
132:
1885:
1837:
1775:
1707:
1599:"How 'price-cutting' middlemen are making crucial drugs vastly more expensive"
873:
An Incomplete Prescription.President Trump’s Plan to Address High Drug Prices.
430:
273:
208:
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546:
404:
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218:
was one of the earliest examples of a PBM which came from within a national
175:
980:"To Lower Your Medicare Drug Costs, Ask Your Pharmacist For The Cash Price"
918:
728:"F.T.C. Slams Middlemen for High Drug Prices, Reversing Hands-off Approach"
596:
580:
261:), and as subsidiaries of managed care plans or insurance companies (e.g.,
143:, and state government employee plans. PBMs are designed to aggregate the
1785:
1744:
1700:
646:
434:
300:
In October 2015 Express Scripts began reviewing pharmacy programs run by
258:
1157:"Leveling the Playing Field in the Pharmacy Benefit Management Industry"
131:. Providers which use such pharmacy benefit managers include commercial
1696:
623:"Vermont latest state to sue PBMs for allegedly driving up drug prices"
426:
92:
675:"The Opaque Industry Secretly Inflating Prices for Prescription Drugs"
642:"FTC says prescription middlemen are squeezing Main Street pharmacies"
887:"States on the Front Line: Addressing America's Drug Pricing Problem"
442:
374:(Employee Retirement Income Security Act of 1974) hearing noted that
301:
127:
to handle price negotiations, insurance claims, and distribution of
99:) comprise 78% of the market and cover 180 million enrollees.
48:
programs for commercial health plans, self-insured employer plans,
1364:"FTC Releases Interim Staff Report on Prescription Drug Middlemen"
1328:"Catamaran Shareholders Approve Acquisition by UnitedHealth Group"
1281:"2014 ERISA Advisory Council: PBM Compensation and Fee Disclosure"
371:
752:"To lower prescription drug costs, states head to the courthouse"
253:), as part of retail pharmacies, major chain drug stores (e.g.,
27:
Administration of prescription drug programs in the United States
2080:
Pharmacy benefit management companies based in the United States
934:"Why Does Medicine Cost So Much? Here's How Drug Prices Are Set"
438:
1717:
1028:"Trump signs bills aimed at increasing drug price transparency"
342:
for about $ 12.8 billion to extend grow its PBM business.
123:
In the United States, health insurance providers often hire an
785:"Feds poised to sue pharmacy gatekeepers over high drug costs"
1122:"Big Pharmacy-Benefit Managers Increase Drug Costs, FTC Says"
1100:"Explainer: Why are US pharmacy benefit managers under fire?"
1713:
1008:. National Conference of State Legislatures. Archived from
1304:
1500:. Upper Saddle River, New Jersey, USA: FT Press. p.
1231:"Pharmacy-Benefit Managers at Times Toil for Drug Firms"
875:
JAMA. 2018;319(23):2373–2374. doi:10.1001/jama.2018.7424
1619:"Do prescription drug middlemen help keep prices high?"
1670:"Pharmacy benefit managers face bipartisan criticism"
1487:
1485:
1391:"Express Scripts takes $ 14 billion bridge loan"
1436:
1434:
1410:
1408:
640:
Gibson, Kate (July 9, 2024). Lee, Anne Marie (ed.).
392:
United States Secretary of Health and Human Services
1984:
1921:
1878:
1804:
1751:
148:without consulting face-to-face with a pharmacist.
1493:
1150:
1148:
1146:
1144:
1142:
1072:
1049:
957:"Why a patient paid a $ 285 copay for a $ 40 drug"
673:Robbins, Rebecca; Abelson, Reed (June 21, 2024).
726:Abelson, Reed; Robbins, Rebecca (July 8, 2024).
1184:
1182:
268:As of 2015, the three largest public PBMs were
1346:"Pharmacy-Benefit Managers – The Short Answer"
885:Riley, Trish; Lanford, Sarah (April 3, 2019).
79:, indicating their increasingly large role in
1729:
1468:"The Short Answer: Pharmacy-Benefit Managers"
68:), and as part of insurance companies (e.g.,
8:
1496:Reasonable Rx: Solving the Drug Price Crisis
1193:. Hartford, CT: Connecticut General Assembly
1155:Allison Dabbs Garrett; Robert Garis (2007).
803:"Pharmaceutical Care Management Association"
365:Centers for Medicare & Medicaid Services
1736:
1722:
1714:
465:Pharmaceutical Care Management Association
350:In 1998, PBMs were under investigation by
338:In March 2015 UnitedHealth Group acquired
1470:. The Wall Street Journal. March 30, 2015
311:Valeant Pharmaceuticals International Inc
141:Federal Employees Health Benefits Program
54:Federal Employees Health Benefits Program
1796:Separation of prescribing and dispensing
207:In 1968, the first PBM was founded when
535:"What is a 'Pharmacy Benefit Manager?'"
480:
292:In 2012 Express Scripts acquired rival
64:), as part of retail pharmacies (e.g.,
1492:Stan Finkelstein; Peter Temin (2008).
871:Sarpatwari A, Avorn J, Kesselheim AS.
830:. Pew Charitable Trusts. March 8, 2019
1573:"PBM Compensation and Fee Disclosure"
1525:Balto, David A. (November 17, 2015).
1441:Pfeifer, Stuart (December 16, 2011).
1229:Martinez, Barbara (August 14, 2002).
1189:Brierton, Janet (December 24, 2003).
1115:
1113:
1093:
1091:
778:
776:
774:
750:Chatlani, Shalina (August 15, 2024).
7:
745:
743:
668:
666:
664:
616:
614:
507:Feldman, Brian S. (March 17, 2016).
502:
500:
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494:
492:
490:
488:
486:
484:
1415:Beasley, Deena (October 30, 2015).
1026:Maegan Vazquez (October 10, 2018).
306:Teva Pharmaceuticals Industries Ltd
216:Diversified Pharmaceutical Services
1389:Sierra, Michelle (July 22, 2011).
1279:Danzon, Patricia (June 29, 2014).
1120:Whyte, Liz Essley (July 9, 2024).
1098:Aboulenein, Ahmed (July 9, 2024).
1077:Tooltip Public Law (United States)
1054:Tooltip Public Law (United States)
955:Megan Thompson (August 19, 2018).
707:Weixel, Nathaniel (July 9, 2024).
621:Pierson, Brendan (July 18, 2024).
25:
1597:Hiltzik, Michael (June 9, 2017).
1215:Essentials of Managed Health Care
1001:Richard Cauchi (March 14, 2018).
2054:
2053:
2014:List of pharmaceutical companies
1672:. Financial Times. April 9, 2019
1161:Valparaiso University Law Review
2034:Pharmacies in the United States
278:United Health/OptumRx/Catamaran
220:health maintenance organization
209:Pharmaceutical Card System Inc.
135:, self-insured employer plans,
81:healthcare in the United States
1212:Kongstved, Peter Reid (1995).
251:Veterans Health Administration
62:Veterans Health Administration
1:
932:Laura Entis (April 9, 2019).
903:10.1080/01947648.2019.1645544
783:Sisco, Josh (July 10, 2024).
978:Susan Jaffe (May 29, 2018).
849:Jack Torry (April 9, 2019).
346:Controversies and litigation
276:(formerly CVS Caremark) and
77:pharmaceutical manufacturers
2009:Pharmacy benefit management
1218:. Vol. 1. p. 304.
1191:"Pharmacy Benefit Managers"
2096:
470:Preferred pharmacy network
225:(now United HealthGroup).
163:
2049:
1254:Cornell Law Review Online
1233:. The Wall Street Journal
891:Journal of Legal Medicine
42:third-party administrator
18:Pharmacy Benefit Managers
2004:Investigational New Drug
1845:Pharmaceutical chemistry
1791:Pharmacological activity
1368:Federal Trade Commission
419:Federal Trade Commission
197:Federal Trade Commission
113:Federal Trade Commission
34:pharmacy benefit manager
32:In the United States, a
1986:Pharmaceutical industry
1805:Pharmaceutical sciences
853:. The Columbus Dispatch
352:Assistant U.S. Attorney
183:Net effect on consumers
145:collective buying power
1419:. Los Angeles: Reuters
581:10.1001/jama.2018.4269
294:Medco Health Solutions
240:Market and competition
1961:Pharmacist prescriber
1946:Consultant pharmacist
1443:"Money & Company"
423:conflicts of interest
376:vertically integrated
340:Catamaran Corporation
313:'s partner pharmacy,
137:Medicare Part D plans
50:Medicare Part D plans
2029:Pharmacies of Norway
1966:Pharmacy informatics
1860:Pharmacoepidemiology
1769:Prehistoric medicine
315:Philidor Rx Services
166:Formulary (pharmacy)
1976:Veterinary pharmacy
1908:Pharmacy technician
1870:Pharmacocybernetics
1764:History of pharmacy
1704:, December 14, 2023
1350:Wall Street Journal
1126:Wall Street Journal
539:Wall Street Journal
176:insurance copayment
1971:Specialty pharmacy
1934:Community pharmacy
1903:Pharmacy residency
1332:www.prnewswire.com
1015:on March 21, 2018.
733:The New York Times
679:The New York Times
417:In July 2024, the
410:In June 2024, the
334:UnitedHealth Group
263:UnitedHealth Group
129:prescription drugs
97:UnitedHealth Group
70:UnitedHealth Group
2067:
2066:
2024:Pharmacy in China
1951:Hospital pharmacy
1929:Clinical pharmacy
1865:Pharmacovigilance
1781:Prescription drug
1625:. August 11, 2018
1604:Los Angeles Times
1447:Los Angeles Times
1352:. March 30, 2015.
575:(22): 2269–2270.
385:Los Angeles Times
247:Kaiser Permanente
223:United HealthCare
58:Kaiser Permanente
46:prescription drug
16:(Redirected from
2087:
2057:
2056:
2019:Medication costs
1994:Drug development
1956:Nuclear pharmacy
1833:Pharmacogenomics
1821:Pharmacodynamics
1817:Pharmacokinetics
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533:Gryta, Thomas.
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460:Online pharmacy
455:Cost Plus Drugs
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348:
336:
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288:Express Scripts
270:Express Scripts
242:
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185:
168:
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125:outside company
121:
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1423:November 1,
1397:October 31,
1326:Catamaran.
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327:Caremark Rx
1886:Pharmacist
1838:Toxicology
1776:Medication
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476:References
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321:CVS Health
302:AbbVie Inc
274:CVS Health
1582:March 29,
1552:"Article"
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1307:. OptumRx
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405:Ron Wyden
395:Alex Azar
160:Formulary
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1745:Pharmacy
1701:On Point
1374:July 12,
1311:June 20,
919:31503529
857:April 9,
789:Politico
713:The Hill
647:CBS News
597:29625496
449:See also
435:Kentucky
325:In 2011
259:Rite-Aid
2039:History
1752:General
1676:June 4,
1266:2234212
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1073:Pub. L.
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1939:shop
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