Preserve Patient Access to Neighborhood Pharmacies


Studies and Data

AHCA Commissioned Analysis of FL Medicaid Confirms Over $90Million in PBM Spread Pricing

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This recent independent analysis of Florida Medicare commissioned by the Agency for Health Care Administration (ACHA) sheds light on PBM fee and pricing practices in Florida's Statewide Medicaid Managed Care System (SMMC). The analysis confirms that PBMs have taken over $90 Million per year in excess profits through the use of spread pricing.

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?

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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.

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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.

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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.

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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

House and Senate in sync on PBM reform

Florida Politics, January 13, 2020 Will this be the year that Floridians at long last receive some financial relief from prescription drug costs? Physicians, pharmacists, and patients certainly hope so. One of the major issues heading into the 2020 Legislative Session is the role Pharmacy Benefit Managers (PBMs) play in setting prescription drug prices. PBM detractors often cast them as middlemen behind the rise of prescription prices. To that end, lawmakers have passed legislation eroding their profession in recent years. According to the Pharmaceutical Care Management Association (PCMA), a PBM trade association, their role is a little more nuanced. In their estimation, pharmacists deserve a share of […]

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Pharmacy benefit managers are making decisions that harm my Tallahassee patients | Opinion

Tallahassee Democrat, January 11, 2020 There are people with no medical training and no obligation to patients who have the power to override medical decisions made by patients and their physicians. These people are pharmacy benefit managers — called PBMs. These pharmaceutical middlemen claim their role is to negotiate savings on prescriptions for patients. But their scope extends dangerously beyond business negotiations. They can decide whether patients can receive the treatments recommended by their physicians. These are businessmen, not medical professionals — and they are altering the care patients receive. Many of my patients in Tallahassee have had their health jeopardized by these dangerous practices. Delays from PBMs recently left one of my […]

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Tom Wright bill pushes for pharmacy benefit manager reform

Florida Politics, December 24, 2019 State Sen. Tom Wright is pushing legislation for the upcoming 2020 Session that would increase regulation of pharmacy benefit managers (PBMs). A PBM is a company that helps determine which drugs will be covered by insurance plans. PBMs negotiate on behalf of insurers to secure discounts from drug manufacturers. But critics argue patients are being left behind when it comes to benefiting from any prospective savings. Wright’s bill (SB 1338) would up state-level regulation of those PBMs in several areas. First, it would increase the ability of the Office of Insurance Regulation (OIR) to examine the practices of those PBMs. Health insurers, health […]

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How pharmacy benefit managers dictate care | Column

Tampa Bay Times by: Dr. Michael Diaz December 26, 2019 When patients are battling a life-threatening disease like cancer, they want a skilled and qualified physician advising them about treatment plans and the best way to beat this insidious disease. But that’s not always what they get. Sometimes, predatory middlemen called pharmacy benefit managers insert themselves into the decision-making process between the doctor and patient. As just one example, our team was working with a patient who had metastatic kidney cancer. Both the medical oncologist and urologic surgeon determined that the patient was not a candidate for surgery because of the patient’s other health conditions […]

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Florida lawmakers push to improve access to prescription drugs, lower costs

The Capitolist December 20, 2019 Calling out Pharmacy Benefit Managers, or “PBM’s” for predatory business practices, a bipartisan group of lawmakers that includes Republicans Jackie Toledo and Randy Fine, Democrat State Rep. Kamia Brown and Democrat State Senator Jose Javier Rodriguez, unveiled new legislation this week designed to increase Floridian’s access to prescription drugs while lowering costs. The proposal would limit the practice of forcing patients to get their prescription drugs from pharmacies owned by pharmacy benefit managers. At a news conference announcing the plan, the lawmakers were joined by patients, doctors and pharmacists and small business owners who say PBM’s are pocketing most of the alleged savings they are able to […]

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Proposed Florida legislation targets pharmacy benefit managers

Tampa Bay Business Journal December 18, 2019 In an attempt to lower health care costs for Floridians, a Tampa Republican and other lawmakers want to crack down on the role of pharmacy benefit managers. Rep. Jackie Toledo held a news conference Tuesday to announce a proposal (HB 961) that would create a new law called the “Prescription Drug Cost Reduction Act” and make clear that certain practices, such as directing patients to pharmacies owned in whole or in part by pharmacy benefit managers should be prohibited. The 53-page bill was lauded by the Florida Pharmacy Association, which maintains that so-called PBMs are driving independent pharmacies out of business. But […]

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