Preserve Patient Access to Neighborhood Pharmacies
Studies and Data
AHCA Commissioned Analysis of FL Medicaid Confirms Over $90Million in PBM Spread Pricing
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.
Who do PBM predatory tactics hurt?
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.
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.
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.
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.
Florida Daily December 19, 2019 Florida state Rep. Jackie Toledo, R-Tampa, was joined by fellow lawmakers, patients, physicians, pharmacists, and small business owners this week to announce legislation that she says would increase Floridians’ access to prescription drugs while lowering costs. Supporters of the legislation say new legislation is needed to directly address what has been called “predatory practices” by Pharmacy Benefit Managers (PBMs). “Our priority is advocating for Floridians who have felt the pinch in their wallets because profit-driven policies by PBMs are robbing patients of savings that should rightly be theirs,” said Toledo. “Consumers need to know that their state lawmakers are fighting for their […]Read More
Florida Politics December 19, 2019 Rep. Jackie Toledo filed legislation Tuesday to crack down on what she describes as over-charges on prescription medication caused by predatory practices among Pharmacy Benefit Managers, or PBMs.” Those are pharmacy middlemen established to facilitate claims approval for medications that require authorization in real-time. The bill (HB 961) addresses the pricing disparity between how much PBMs charge insurance providers compared to how much they reimburse pharmacies, paying self-owned pharmacies more than other pharmacies or steering patients to pharmacies they own and PBMs not passing along savings from third-party rebates. The bill would also increase transparency by requiring all information, including PBM revenue, to be reported […]Read More
Health News Florida December 18, 2019 A Tampa lawmaker is hoping to lower drug prices and improve care for Floridians by regulating companies that serve as middlemen in the health care industry. Rep. Jackie Toledo, R-Tampa, filed legislation on Tuesday that would rein in the industry that helps decide how consumers get their pharmaceuticals and how much they will pay for them. Pharmacy Benefit Managers, or PBMs, such as CVS Caremark, Optum RX and Express Scripts control roughly 80 percent of the market in Florida and around the country. That means they have a large say in which medications make it on a list of […]Read More
Bay News 9 December 17, 2019 State Rep. Jackie Toledo officially announced a new bill Tuesday that she said is designed to lower prescription drug costs while increasing pharmacy access to all patients. State Rep. Toledo outlines Prescription Drug Cost Reduction Act HB 961 is gaining bipartisan support Toledo says pharmacy benefit managers are price gouging Surrounded by pharmacy owners, patients, other state representatives, and even doctors, she outlined the Prescription Drug Cost Reduction Act. “The PBMs would have to disclose how they are making their money, and it would prohibit the practice of spread pricing, which is charging someone more than what the drug actually costs, […]Read More
Tampa Bay Times December 17, 2019 Jackie Toledo recently had an issue with the cost of medication. It’s a problem the Republican state representative from South Tampa said she’s heard too many times before. Toledo said this kind of scenario is happening way too often. That’s why she’s filing a bill today to regulate pharmacy benefit managers, or PBMs. The measure, she said, would keep drug costs down for consumers and independent pharmacies in Florida. Called the Prescription Drug Cost Reduction Act, the bill aims to prohibit health care monopolies that reduce patient choice, and to eliminate the practice of “steering” patients to PBM-owned pharmacies. […]Read More
Fox 13 News December 17, 2019 A Florida lawmaker is pushing to make your next trip to the pharmacy easier and less expensive under a proposed bill to cut price gouging for drugs and give you more choice on where to get prescriptions filled. Loretta Boesing will never forget the day something went wrong with her son’s medication. “My son, Wesley had a liver transplant at the age of 2. And after they shipped his medications in only a bag on a 102-degree day, he ended up going into liver transplant rejection,” said Boesing. The medicine was not at the right temperature, which could destroy […]Read More