The Hidden Power of Pharmacy Benefit Managers: A Closer Look

Pharmacy Benefit Managers (PBMs) have been around for over half a century, acting as intermediaries in the pharmaceutical industry. However, recent criticisms suggest that these ‘middlemen’ may be wielding too much control over healthcare decisions, with patients bearing the brunt of the consequences.

The Role of PBMs
PBMs are responsible for constructing formulary lists that detail which brand-name or generic medications an insurance plan will cover. This process has been accused of driving up drug prices due to competition for favorable positions on these lists. PBMs also employ “utilization management” policies designed to control healthcare spending. These measures include requiring prior authorization before a prescription can be filled, step therapy, and limiting how much of a medication can be filled or in what dose.

The Impact on Patients
Patients, doctors, and pharmacists argue that these measures have given PBMs too much control over life-sustaining medications. For example, a doctor may want to prescribe a specific insulin for a diabetes patient, but the patient’s plan may only cover it if the patient tries a different brand first and it doesn’t work for them. This can lead to delays in treatment and unnecessary suffering for patients.

The Industry’s Defense
PBMs and industry groups claim that their decisions are made using clinical guidelines in the interest of cost savings and improved health outcomes for patients. They argue that processes like step therapy and prior authorization have benefits such as catching potential drug interactions or preventing over-prescribing of addictive painkillers.

While PBMs argue they are working to lower costs and improve outcomes, critics maintain that these ‘middlemen’ have too much control. The debate continues, with patients caught in the middle, often paying the price. As the discussion evolves, it’s clear that more transparency and regulation may be needed to ensure that patients’ needs are prioritized in the healthcare system.

Reference Article: Permission to Prescribe: Physicians allege insurance intermediaries, red tape are driving decisions about care with patients paying the price