One of the things that pharmacy benefit managers (PBMs) do is prohibit pharmacists from telling patients when they could save money by paying cash rather than using their insurance plan. In fact, according to a recent NBC Nightly News segment, pharmacists can be fined thousands of dollars for telling patients they can save money. According to the New York Times (as reported by the Dallas Morning News here) much of the difference between the lower “cash” price and the higher “insurance” price goes directly into the pockets of the PBMs.
Fortunately, state lawmakers are taking aim at these so-called “gag clauses,” helping ensure that patients are informed of the lowest price for a medication. The Alliance for Transparent and Affordable Prescriptions (ATAP) reported that Virginia is the latest state to have passed a bill addressing the PBM practices. Virginia’s HB 1177, currently waiting for the governor’s signature, ensures that PBMs allow pharmacies to tell patients when a more affordable option is available and to sell them the more affordable alternative when requested.
Virginia joins Connecticut, North Carolina, Georgia, Maine, and North Dakota that currently have enacted similar laws and a dozen other states are considering legislation to prohibit gag orders.
As discussed in my earlier post, PBMs wield an incredible power when it comes to both access to and cost of medications. PBMs are the organizations that basically set the rules for drug insurance plans. PBMs decide, for example, if medications are even covered (in formulary), at what tier (cost level) they’re covered, and whether other drugs must be taken first (step therapy). These practices have come under scrutiny as whether they might actually be harmful to patients by delaying or even denying access to needed treatments.
On the other side of the discussion is the Pharmaceutical Care Management Association which represents PBMs and which, among other activities, has filed suit to keep these laws from being enforced.
I understand that managing pharmacy benefits is a highly complex business. Like any other supply-chain model there are elements of supply and demand and the need to balance margins across an incredible array of highly sophisticated medications. But medicine needs to be about the patient and purposefully deceiving patients about the cost of their medications does not meet this critical standard.