Historically, PBMs are considered “the enemy” when it comes to the world of pharmacy. It makes sense, seeing as how the pharmacy benefit managers are often a barrier to timely patient care. Whether the medication is not covered, it needs a prior authorization, or maybe step therapy.
What if there was a different way?
Independent pharmacies are seeing large decreases in reimbursements from insurance and Specialty independent pharmacy is no better. Specialty medications are generally more costly (oral Hepatitis C medications can cost upwards of $30,000 for one month’s supply) and often have special handling or administration requirements, such as injectables or infusions. Specialty pharmacies face hurdles like negative reimbursements, PBM “lockouts” and limited distribution drug constraints. PBM lockouts occur when a pharmacy attempts to fill a specialty medication and sees “Must fill at a network specialty pharmacy” on the rejection screen of the computer. Limited distribution drugs are prescription products that are only accessible from a handful of specialty pharmacies so the manufacturing company can have more oversight and control.
What’s even more frustrating is that sometimes these specialty pharmacies have a relationship with a nearby health system and the pharmacy may not be able to service the employees of that health system due to one or more of these restrictions.
The current (antiquated) model is as follows:
A health system contracts with a PBM to administer their health plan and process medical and pharmacy claims. The PBM acts as a middleman between the health system (or hospital) and the pharmacy. The PBM also charges the health system an exorbitant amount of fees to handle this business. This is called the PBM “spread”. The worst part is that the PBM reimburses the pharmacy a different (much less) amount than they charge the health system for the same drug! PBMs are very secretive about these charges and are accused of not being transparent.
None of these practices benefit our patients and provide for a higher quality standard of care.
Cut out the middleman and maintain your hard-earned affiliations. Even make new ones with this new model. Enter into a network where limited distribution drugs and specialty rejection lockouts are nonexistent. Our model removes the PBM middleman and aligns health systems and independent pharmacies to serve patient populations while removing the shell game that gets in the way of the independent pharmacy’s success. Referral centers can then work with independent pharmacies in their community and return pharmacy to where it belongs, keeping dollars at home as opposed to sending them to big box chain pharmacies.
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