Middlemen are often standing between patients and their medicines.
Insurance companies use pharmacy benefit managers (PBMs) to decide if medicines get covered and what people pay. Just three PBMs control 80% of the prescription drug market, and last year, they denied coverage to more than 1,150 medicines.
When people are sick, they should be fighting their illness, not middlemen.
Patients can pay more for medicines than middlemen
Insurance companies and PBMs get savings that can reduce the cost of some brand medicines by 50% or more. But they don’t have to share these savings with patients at the pharmacy.
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Middlemen benefit at patient expense.
When patients use copay assistance to save money at the pharmacy, insurance companies and PBMs don’t always count that amount toward their annual deductibles. The result? Patients end up paying more.
Middlemen’s business model can lead to higher costs for everyone.
Middlemen say they want lower prices, yet they often deny or limit coverage of lower-cost generics and biosimilars. That’s because PBMs are charging fees tied to the price of medicines, which means they make more money when the price of medicine goes up. This allows PBM profits to soar and experts warn it can lead to higher costs for everyone.
Middlemen can profit from where patients fill their prescriptions.
Insurance companies and PBMs can steer people toward pharmacies that make them more money. Why? Because these middlemen own the pharmacy too.
It's time to lower costs for patients by holding middlemen accountable.
Related Resources
New analysis shows PBMs use fees as a profit center
Pharmacy benefit managers (PBMs) demand more than double the amount of fees today than they did five years ago, according to a new report from Nephron Research.
Hold PBMs Accountable: Rein in Middlemen Tactics that Harm Patients
By demanding more accountability and transparency, Congress can help rein in abusive PBM practices and provide meaningful relief to patients and taxpayers.
Share the Savings: If Insurers Don’t Pay Full Price for Medicines, Seniors Shouldn’t Either
Many Medicare beneficiaries struggle to afford the medicines they need, even as insurers and pharmacy benefit managers (PBMs) in the Part D program receive significant rebates from drug manufacturers that lower the prices they pay for medicines.
Protect Copay Assistance: End Insurer and Middlemen Games That Drive Up Costs for Patients
Patients continue to show up at the pharmacy counter and realize their commercial health insurance coverage doesn’t provide the level of access and affordability they need. A big reason is because insurers and pharmacy benefit managers are shifting more costs onto patients through higher use of deductibles and coinsurance.
A Patient's Perspective: Katie McKoy
Caregiver to her son Matthew
Voters like Katie, a Georgia caregiver, overwhelmingly support solutions to help rein in insurance companies and their pharmacy benefit managers (PBMs). Join her in raising your voice to ensure that patients and doctors are the ones making decisions about medications, not PBMs who are more focused on bottom lines than quality of life.