A middleman refers to1/10/2024 This happened over 150 times in 2021, with rosuvastatin and with "several other medications," he noted. The result of the formulary change was "an unnecessary out-of-pocket spend" for the patient and a "windfall" for the PBM, which then collected money that it characterized as "overpayments" to pharmacies under the new pricing structure, even though the pharmacy itself had not received the extra money, according to Oftebro's written testimony. (A 90-day supply of rosuvastatin cost $10 to buy from a drug wholesaler, while the "highly inflated and completely arbitrary," as Oftebro put it, average wholesale price (AWP) was $805.40 for 90 tablets.) In 2021, a PBM moved a generic cholesterol drug, rosuvastatin (Crestor) from tier 1 to tier 3 of the formulary and raised copays from $15 to $141 for the same 90-day supply. In his opening statement, Ryan Oftebro, PharmD, owner of Kelley-Ross Pharmacy Group in Seattle and an associate professor at the University of Washington School of Pharmacy, shared examples of PBM abuses. Physicians, particularly oncologists, often modify treatments to optimize them and mitigate toxicities, sometimes as quickly as 1 or 2 weeks after starting a medication, However, PBMs sometimes require scripts that must be filled for a 90-day supply, which means patients often end up with a month or even 2 months' supply of a drug they can't use, Patt said.įor independent pharmacies, PBMs create a whole other set of challenges. And because it would have caused less toxicity, Tania likely would have been able to continue working and live a "more normal life," Patt said.Īnother problem with PBMs is that they create "extremely expensive waste," she said. While she can't say definitively that Tania would be in better health had she received abemaciclib, the literature suggests Tania might have doubled her chances of living without her cancer progressing, in comparison to chemotherapy. As of last week, Tania has two new brain metastases for which she'll need radiation. As she watched Tania's cancer grow, Patt knew she could not wait for the PBM and insurer to approve her appeal for abemaciclib, and so she turned to "less effective and more toxic chemotherapy," she said. Tania, a 40-year-old woman with metastatic breast cancer who is one of Patt's patients, was blocked by a PBM from accessing abemaciclib (Verzenio), which Patt believed to be one of the most effective treatment options for Tania's particular case. ![]() "The delays and detours are difficult to anticipate and limit a doctor's ability to effectively control the cancer," which can result in "poor disease control, morbidity, and mortality for the patients we serve." Congress is determined to rein in these "mysterious middlemen," Cantwell said, and won't be deterred by things like the complexity of the drug-pricing system.ĭebra Patt, MD, PhD, a breast cancer specialist for Texas Oncology in Austin and vice president of the Community Oncology Alliance, said PBMs can threaten patients' access to care.Ĭancer patients need timely access to treatment, and PBMs, by steering prescription fills to specialty and mail-order pharmacies, have denied and delayed that care, she said. This leaves independent pharmacies, care providers, and patients with no other options when PBMs raise their prices, she said. Three PBMs currently control 80% of the market, Cantwell noted, with pharmacy chains and health insurers buying up the biggest PBMs. "However, a wave of consolidation and other activities in the last few years have distorted behavior," Trish said. When PBMs first entered the healthcare space, they were independent from health plans and helped bring down prices by encouraging more use of generic drugs and by increasing mail-order services, explained Erin Trish, PhD, an economist and co-director of the USC Schaeffer Center at the University of Southern California School of Pharmacy. And "the evidence suggests that PBMs are part of the high drug cost increase." "Since 2014, prescription drug prices have increased 35%, outpacing increases in wages, gas, internet service, and food," committee chair Maria Cantwell (D-Wash.) said at Thursday's hearing. Three of the four witnesses - an economist, a physician, and a pharmacist - called on Congress to require greater transparency and accountability from PBMs. ![]() Pharmacy benefit managers (PBMs) - middlemen between pharmacies, health insurers, and drug companies - are responsible for driving up prescription drug prices and shuttering independent pharmacies, witnesses said during a hearing held by the Senate Commerce, Science, & Transportation Committee.
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