We know that PBMs make tons of money from paying pharmacies very little for drugs and then charging crazy prices to employers or insurance companies for the prescription that was dispensed. Our most recent PBM story involves one of the largest PBMs in the country. But, they all work the exact same way.
We had a Hospice patient that needed a medication. In general, the PBMs will cover dirt cheap drugs with no problem. But, this drug cost a little more than dirt. Our cash price would have been $60 on it if someone walked in off the street. When we submitted the claim to the PBM, it was rejected needing a special approval. The Hospice nurse called the PBM and the PBM informed her that the Hospice group would be charged $260 by the PBM.
Usually, for a generic drug with a cash price of about $60, a PBM will usually pay the pharmacy about $50. They never pay us more than what an uninsured cash price would be. What we learned from this exchange was that the PBM spread for that particular drug is over $200 per prescription. We would do all of the work and make a tiny profit…..like $2-5 if lucky. But the PBM, who does nothing except push paper, makes $210.
And it only continues to get worse. PBM reimbursements get worse and worse every year. The top PBMs reimburse pharmacies below cost on virtually every brand name prescription that is filled. Ten years ago, pharmacies at least made a little money on every brand name prescription. Not anymore. The worst part is they have lied to legislators and the public about what they do and they refuse to be transparent with the truth. So many insurance and Hospice companies use PBMs and have no idea that they are overpaying for prescriptions.