Preserve Patient Access to Neighborhood Pharmacies

Studies and Data

Independent study highlights extent of PBMs' predatory practices in Florida's Medicaid program

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This independent study from 3 Axis Advisors was developed using data straight from the state Agency for Health Care Administration. The analysis covers more than 350+ million prescription claims in Florida between 2012 and 2019, coupling that data with information from 100+ pharmacies. Some of the most shocking tactics the report uncovers involve the routine practice of PBMs and managed care organizations "steering" patients to affiliated pharmacies and then paying those pharmacies more than other ones for the same drug.

Legislative Leaders are Calling for Action

“Markets fail when markets get corrupted and that is what has happened here. When the middleman is allowed to own the end-retailer then the middlemen’s incentive to manage cost appropriately for the benefit of the chain is broken. And that is what has happened here.”

-- Rep. Randy Fine

“The power and control of PBMs has grown significantly over the last five to ten years. What we’re seeing is insurance companies owning PBMs and PBMs owning insurance companies. What is happening in the long run is that the price of prescriptions are going up.”

-- Sen. Gayle Harrell

“The practices PBMs use to drive up profits are complex, but the solution is simple: We need to increase access to care for all Floridians while ensuring that prescription drug savings make it to the patient and not the pockets of predatory PBMs.”

-- Rep. Jackie Toledo

When it comes to PBMs,
we all pay the price.

Pharmacy Benefit Managers (PBMs) are middlemen who have strayed from their original purpose of negotiating savings for patients and now keep the profits for themselves, leaving the rest of Florida’s consumers to pay higher drug prices. PBMs use anti-competitive practices to short-circuit the free market and create health care monopolies.

These predatory tactics decrease access for patients, force neighborhood pharmacies to close down, and raise costs for everyone. We need legislation that will increase transparency and accountability on PBMs and ensure that patients are prioritized over profits.

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Who do PBM predatory tactics hurt?

Patients

Forcing neighborhood pharmacies out of PBM health networks causes many patients to drive extra miles from their home to receive medications simply because their local pharmacy is not in their plan. This not only steers business away from neighborhood pharmacies, it severely restricts patients’ access to medications and drives up their costs.

Pharmacists

Many neighborhood pharmacies diligently refill prescriptions only to be hit with reimbursements that are pennies on the dollar – with some even facing negative reimbursements or clawbacks – while PBMs continue to make record-breaking profits. No business can sustain operations under this model, and it is a clear manipulation of the system that promotes anti-competitive practices.

Providers

PBMs are overstepping their scope and making medical decisions best left to physicians and pharmacists – and their years of training. PBMs are motivated by profit, not by what is best for the patient, and many times PBMs require the use of drugs or specialty medications that are not the most beneficial for the patient.

Payors

The anti-competitive policies that PBMs push increase health care costs for everyone. PBMs don’t make or provide the drug – they don’t even touch the drug – yet they add costs to the overall health care system that must be absorbed by pharmacists, patients, and all Floridians.

How Can We Fix This?

This year, the Florida Legislature is considering legislation to address these challenges. SB 1444 and HB 961 implement transparency, accountability, and free-market policies that will help preserve patient access and keep drug prices affordable.

Here are some highlights of the legislation:

Protect the free market by prohibiting anti-competitive policies that reduce patient choice and create health care monopolies
Eliminate the practice of steering patients to PBM-owned pharmacies, especially when it involves taxpayer dollars
Prohibit the predatory practices that PBMs use to squeeze independent pharmacies, including post-adjudication fees, spread pricing, and cumbersome audit practices

By supporting this legislation, we can bring about concrete change in the industry and put a stop to the abuses that leave Floridians suffering.

News

FLORIDA’S SECRET DRUG PRICING SCAM YOU’VE NEVER HEARD OF

Medium.com Though you may have never heard of them, pharmacy benefit managers (PBMs) play a critical role in the price you and I pay for prescription drugs at the pharmacy. Like rats in a sewer, PBMs thrive on secrecy. Once the processors of prescription drug claims, today the largest PBMs are subsidiaries of the largest health insurers, helping corporations like CVS Health and UnitedHealth leap to 5th and 7th place respectively on the Fortune 500 — just behind better-known corporations like Walmart, Amazon, and Apple. Bear in mind PBMs and insurers don’t manufacture a product or provide a service. They’re simply extremely wealthy middlemen. PBMs […]

What “Big Insurance” Doesn’t Want You to Know About Community Pharmacies

Medium.com Patients and pharmacists share a special relationship, often stretching back generations. Even the frightening spike in drug costs can’t erode the feeling of trust and care we feel when walking into our neighborhood pharmacy. But “neighborhood pharmacies” as we know them are rapidly disappearing, victims of large corporate pharmacy benefit manager (PBM) “middlemen” that now dominate the drug industry. If you’ve never heard of PBMs, you’re not alone. The largest PBMs own or are owned by, well-known health insurers (UnitedHealth; CVS Health, CIGNA) — and all own or have affiliate relationships with their own pharmacies. If you’re a die-hard CVS or Walgreens shopper, you […]

Prescription for Transparency

California Business Journal – August 25, 2020 Pharmacy Benefit Managers (PBMs) were created to be the middleman and negotiate drug prices. Working with the health care providers, pharmacies and the pharmaceutical companies determine reimbursements and what they’d charge the pharmacies. The problem is that without regulation, the PBMs have bad business practices. The fix is on the way. Magnified by the economic and health care impacts of the novel coronavirus, the Florida legislature is honing in on regulations for a long-veiled middleman in the chain of rising prescription drug pricing. Intended to serve as a beneficial consumer go-between for pharmacies and health insurance companies to […]

Pharmacy Deserts Are on the Horizon if PBMs Continue to Underpay Medicaid Reimbursements

Grit Daily – August 17, 2020 Independent pharmacies are being forced into bankruptcy due to underpayment for Medicaid reimbursements, which are managed by Pharmacy Benefit Managers (PBMs.) These small pharmacies are deciding to either turn away Medicaid patients or to close their practices, creating pharmacy deserts in poor neighborhoods. A survey of 123 independent pharmacies in Florida found that over 60% “may be forced to discontinue taking Medicaid patients if changes are not made to the program that currently requires neighborhood pharmacies to sell most prescription drugs at a loss.” 93% declared having to turn away at least one Medicaid patient per month because dispensing to them would […]

Why are neighborhood pharmacies disappearing? Ask the Noriega Family.

Lissette Campos – July 15, 2020 I arrived at Bill’s Prescription Center in Brandon an hour early, half expecting to find a quiet operation with the owner prepping for our television interview. After all, how busy can they be? I’m here because neighborhood pharmacies like this one, close to 100 in the Tampa Bay area alone, are in danger of closing. Common sense would have you believe the disappearing act is caused by a lack of customers. Three minutes in, I realized there’s nothing common sense about this situation. A steady stream of customers didn’t just walk in for their medicines, they arrived for, what […]

Pharmacy Benefit Managers Are the Real Reason Behind Skyrocketing Drug Prices

Grit Daily – April 30, 2020 Why are drug costs so high in America? If you ask Bernie Sanders, he will tell you that it’s due to the greed of the pharmaceutical industry. If you remember when “pharma bro” Martin Shkreli, former CEO of Turing Pharmaceuticals, made the price of the life saving drug Daraprim 5,000% higher overnight, you may agree with this assessment. But, there is more to the story, and it has to do with Pharmacy Benefit Managers (PBM’s). Within the healthcare industry, there are pharmaceutical manufacturers, pharmacists, insurance companies, and Managed Care Organizations (MCO) for Medicaid, but there is one more player that few […]