What Is PBM?
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 control 77% of the market. CVS Caremark, the PBM for CVS, is the second largest PBM in the U.S., accounting for nearly 34% of covered lives. This significant market share allows CVS Caremark (as well as the other largest PBMs) to exercise undue market leverage and generate outsized profits for themselves.
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.
Updated Feb. 24, 2022
On Wednesday, Feb. 23, 2022, Gov. Gretchen Whitmer signed House Bill 4348, MPA’s historic PBM reform bill, into law, along with other bills MPA supported that will reign in PBMs and lower the cost of prescription drugs. HB 4348 will take effect Jan. 1, 2024. Learn more below.
Governor Signs into Law PBM Reform Championed by Michigan Pharmacists Association (Feb. 23, 2022)
Photo: From left to right, Brian Sapita, Michigan Pharmacists Association (MPA) director of government affairs, Heather Christensen, MPA chair, and Mark Glasper, MPA CEO, stand behind Gov. Gretchen Whitmer Wednesday morning, Feb. 23, 2022, following her signature of House Bill 4348, pharmacy benefit manager reform, at Meijer in Lansing, Mich.
What Are DIR Fees?
Under the current system, pharmacy benefit managers (PBMs) – the middlemen hired by plan sponsors to administer prescription drug benefits – often claw back fees from pharmacies well after a transaction. Those fees, called direct and indirect remuneration (DIR), are often unpredictable and seemingly unconnected to a pharmacy’s performance. The fees also disadvantage patients, who are assessed a higher cost-share against their Part D deductible rather than the retroactive, lower adjusted price. The result is to push patients more quickly into the so-called Part D donut hole, at which point the patient is responsible for a considerably larger portion of the costs of their prescription drugs.