'The Middleman'

Over the decades, PBMs have evolved 

significantly. Today, they are central 

players in the healthcare system, responsible for setting drug prices, managing formularies and processing claims. The rise of PBMs have greatly influenced the overall cost structure of prescription medications. 

PBMs have become increasingly regulated in recent years to ensure fair and transparent operating standards.  Every pharmacy has a chance to be a part of this change. Pharmacies  and politicians nationwide are exposing ‘the middleman.’  Submitting MAC appeals is just a small step to push the PBMs back into line. 

PBMs have set theirselves up to be the center of all monetary value in the pharmacy world. In 2016, Drug Channels released an article describing money flow throughout the prescription process.  Starting at the drug  manufacturer and filtering down  to the patient.  This graphic expertly shows the money flow and what pharmacies see on a daily basis.  

The ‘Big Three” PBMs (Express Scripts, CVS, OptumRx) process over 80% percent of all prescriptions in America. In 2022, the Federal Trade Commission released a report listing the reimbursement differences based on affiliated and non-affiliated pharmacies.  The results showed PBMs reimbursing an affiliated pharmacy an astounding 25 times (30%) more than the drug cost (acquisition) than to a non-affiliated pharmacy.  

Pharmacies are loosing money when they dispense a single medication.  Getting correctly reimbursed for the cost of a drug is crucial to keep pharmacies open and give patients access to care.  

 Nationwide, pharmacies are having to turn patients away! When did we have to start choosing money over patients?  PBM reform is happening, and its happening now.