If you’ve ever had trouble getting prescription medications, you may have encountered a pharmacy benefits manager.
These companies, known as PBMs, play a crucial but often hidden role in determining which drugs patients can get and how much they must personally pay. They are middlemen in America's mind-bogglingly complex health care system, working on behalf of government insurance programs like Medicare and employers, who cover most prescription drug costs.
PBMs' job is to save you money on drugs, but The New York Times found that the big three PBMs often get patients to pay higher prices than they should.
Here's what you need to know about PBMs and how to know if you're being overcharged.
How do I know which PBM I have?
Most Americans rely on one of the big three PBMs: CVS Caremark, Express Scripts, or Optum Rx. Even if you use a smaller PBM like Prime Therapeutics, you may be subject to the business practices of the big three (this is because many smaller PBMs outsource some of their business with drug companies and pharmacies to larger competitors).
This is different from health insurance, which covers doctor's visits and hospitalizations. Typically, you can choose a health insurance plan each year during your employer's open enrollment period, but the PBM will make the selection for you.
You'll usually receive an ID card in the mail that identifies which PBM you have, or you may need to contact your employer's human resources department.
If you have Medicare, you get to choose your insurance plan each year, but the government website that lets you compare plans doesn't tell you which PBM is attached to which plan. You might be mailed an ID card that identifies your PBM, or you can call your Medicare plan to find out.
What do PBMs do?
PBMs have the most direct impact on you by selecting which drugs your insurance will cover and determining how much you will pay out of pocket for those drugs.
PBMs create the list of covered drugs, called a formulary. They also decide which drugs to encourage patients to take by making them cheaper. They may charge more for drugs or impose hurdles to discourage patients from taking other drugs, such as requiring them to try other drugs first. The insurance company or employer signs off on the PBM's recommendations.
Is the PBM overcharging me?
If you feel your drug copayments are too high, it can be difficult to determine which party in the health care system is to blame. In some cases, your employer or insurance company, not the PBM, is to blame for providing stingy benefits. But there are some common scenarios in which PBM business practices are the primary cause of high payments.
PBMs sometimes force patients to take brand-name drugs even though cheaper generic versions are available. If you're paying too much for a brand-name drug, ask your doctor or pharmacist if there's a cheaper alternative you could switch to.
Even if you are taking a generic drug, a PBM may force you to pay a higher price than you would if you paid out of pocket without insurance at your local drugstore or online pharmacy. This often happens with generic drugs for chronic conditions such as cancer and multiple sclerosis.
Explore options for paying for your medications out of pocket without insurance, such as GoodRx, which lists prices at nearby pharmacies, or Mark Cuban Cost Plus Drugs Company, an online pharmacy that sells hundreds of medications.
Who can help me?
A good rule of thumb: ask your pharmacist.
“Get to know them. Find out the pharmacists' names and make sure they know yours,” says Stephen Giroux, an independent pharmacist in upstate New York and a vocal critic of PBMs. “We know the prices. We can offer lower-cost alternatives.”
Pharmacists are one of the few experts in the system who have a clear understanding of how PBMs push patients to pay more. Often, pharmacists can step in on the patient's behalf if a PBM is asking them to pay more than they should. For example, they can offer lower prices without insurance or introduce manufacturer coupons that can save you money.
Even if you get your medications mailed to you from a pharmacy that partners with a PBM, such as Accredo, the same company as Express Scripts, it's still worth visiting your local pharmacy to see what options you have.
If you are charged a medicine that is too expensive for you to pay, you can ask the pharmacy whether you can pay in installments.
Can I change my PBM?
it depends.
If you get your insurance through an employer, you can't change PBMs. However, you can complain to your employer. Talk to your HR department first. Often, employers only become aware of a problem when employees complain about the high costs of certain medications.
If you have Medicare and want to change PBMs, you can choose a new plan the following year. Many Medicare plans use the same PBMs, so you'll need to do your research to make sure you're actually choosing a different PBM.
Because there are many options for Medicare plans, the best advice is to focus on the information you can find out, such as the plan's benefits, what drugs the plan covers, how much you'll be paying each month for certain drugs, etc. All of this information can be found on the Medicare website.
