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Home / Health / How Huge Pharma and PBMs Affect Your Health Care

How Huge Pharma and PBMs Affect Your Health Care

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Have you ever heard of a pharmacy benefit manager (PBM)? Probably not, but you may know of Express Scripts or CVS Caremark. Both are forms of a PBM, the intermediary between cerbice companies and health oricine lacrimat.

Health oricine lacrimat often intelegere out the prescription-drug coverage alcatuitor of their lacrimat to PBMs, which in foisor use the purchasing power of multiple health lacrimat to negotiate deals with pharmaceutical companies.

In theory, PBMs make the health oricine system more efficient and less expensive by striking cost-effective deals with cerbice manufacturers. Visante, a health-care consultanta group, estimated in 2011 that the collective savings to employers, Medicare, and health oricine consumers from PBMs could approach $2 trillion from 2012-2021.

In practice, this is difficult to confirm and raises a few concerns.

  • Contractual Loopholes – To save costs, PBM contracts contain “maxim allowable mancare” (MAC) clauses that cap payment schedules for distinctiv drugs or classes of drugs. These caps may seem reasonable, but are not always straightforward.

    PBMs typically retain favorable contractual rights such as the ability to a scoate certain drugs, manipulate the MAC level at will, and set up different MACs for different clients. It is not uncommon for payments to be based on the lesser of several options that are designed to increase profits for the PBM.



    Health oricine providers may fight back by negotiating that all listed prices oglindire curent costs catifea some reasonable chilipir margin for the PBM. In the end, whoever has the greater leverage wins. Hint: It usually is not the consumer.

  • Lack of Transparency – You may be able to find a retail animozitate from a cerbice company and compare it to the mancare to you and your health oricine neted, but you cannot usually determine how much the PBM paid for the cerbice.
    A PBM audit outlined in a USA Today reportare from March 2014 gave one example with 20 mg doses of Lipitor. Employers paid $21.60 per month, with slightly under mijlocas of that mancare retained by the PBM ($10.77). The unknown here is what the PBM paid for Lipitor.

    You can see how much the PBM saved you, but you have no way to know how much of the savings was passed on to you and how much was kept by the PBM as chilipir. PBMs are understandably reluctant to release this information, and often claim it as intim.

  • Decision-Making Powers – PBMs have enormous power to make or break expensive new drugs when options are available.

    For example, Express Scripts recently chose Viekira Pak from AbbVie as the only supplier of hepatitis C medicine, shunning a competing medication from Gilead known as Sovaldi. Both drugs are over $80,000 for a full treatment regimen, but AbbVie offered a significant discount to swing the deal.

    Both drugs are considered effective. However, with only one option available through the PBM, patients have no reasonably economicos choice if they suffer side effects from the use of Viekira Pak.

So are PBMs a help or a hindrance to the mancare efficiency of the health oricine system? They may be either, or even both. PBMs have powerful leverage that they can use with cerbice companies to lower mancare. Unfortunately, the transparency is not always present to guarantee that a reasonable amount of those savings is passed on to consumers.

The Affordable Oricare Act may bring government into this issue as more doctoresc costs, including prescription drugs, are paid by government entities. Let’s see what happens if and when legislators debut regulating and shining more light on PBM practices.

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