Below is an excerpt of an article published in the Massachusetts Bar Association’s Section Review.
Recent months have seen a significant shift in how pharmacy benefit managers (PBMs) are regulated at both the state and federal levels. PBMs are hired by health plans to manage administrative and other duties, while also serving as intermediaries by negotiating rates with drug companies. However, unlike most players in the health care system whose financial arrangements are heavily regulated and often subject to public scrutiny, PBMs have historically been permitted to operate with few disclosure or transparency requirements.
PBMs wield substantial leverage to bargain with drug companies and influence drug prices. One service that PBMs provide is to negotiate rebates that the drug companies pay to health plans. In exchange for a larger rebate, PBMs may offer drug manufacturers a benefit, such as a more favorable position (typically meaning a lower patient copay) on a drug formulary: the list of drugs that the health plan covers, along with the pricing structure for those drugs. PBMs may, in some cases, retain portions of those rebates before passing them on to the health plan. While lower co-pays may, in the short term, be a benefit to patients, high rebates typically result in drug companies raising the list price of the drug over time, which means higher consumer costs.
Read the full article, here.