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?

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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

Watchdog: Insurance Groups Buy Drug “Middle Men”; Transparency Calls Grow

Spectrum News 13 July 23, 2019 PBMs: have you heard of them? If not, you’re not alone, but they do factor into your prescription drug costs. They’re essentially a “middle man” between drug makers, health care plans, and patients, negotiating the prices most of us pay for prescription drugs. n the last two years, health insurance companies, which set deductibles and co-pays, have bought up the three main PBMs: Express Scripts, CVS Caremark, and Optum RX. A number of independent pharmacies have told Spectrum News they are now losing business and revenue because of PBMs, including Five Points Pharmacy in Cocoa, a pharmacy that has been welcoming […]

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Independent pharmacies being driven out of business by ‘predatory middlemen’ | Opinion

South Florida Sun Sentinel October 21, 2019 Lately, everywhere you look there are people worried about keeping drug prices affordable, especially for Florida’s aging seniors. People are voicing their concerns, but many are ignoring one of the biggest factors contributing to reduced access and increased costs — and sometimes driving people like me out of business. Pharmacy Benefit Managers, or PBMs, have been abusing their power for years, remaining undetected as they drive independent pharmacies into the ground. These predatory middlemen no longer serve their original purpose of negotiating medication savings for patients. Instead, they use their corporate clout to force patients to certain pharmacy […]

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Jackie Toledo plans to tackle prescription drug prices by regulating the middleman

Florida Politics December 9, 2019 Rep. Jackie Toledo plans to file legislation this week that would lower prescription drug prices for some consumers and protect small pharmacy owners by regulating what are known as pharmacy benefit managers. Pharmacy benefit managers, or PBMs, serve as middlemen between pharmacies and health insurance companies to provide real-time benefit analysis and actual costs for consumers purchasing prescription medication. These individuals are meant to make it easier for pharmacies to obtain health insurance benefit information on patients so they can get their prescriptions in a timely fashion, but their presence has morphed into what some believe is a profit-driven model that favors insurance […]

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The Secret Drug Pricing System Middlemen Use to Rake in Millions

Bloomberg September 11, 2018 For years, Frahm’s South Side Drug bought pills from distributors, and dispensed prescriptions to the Wapello County jail. In turn, the pharmacy got reimbursed for the drugs by CVS Health Corp., which managed the county’s drug benefits plan. As he compared the newspaper notice with his own records, and then with the county’s, Frahm saw that for a bottle of generic antipsychotic pills, CVS had billed Wapello County $198.22. But South Side Drug was reimbursed just $5.73. So why was CVS charging almost $200 for a bottle of pills that it told the pharmacy was worth less than $6? And what […]

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