Your doctor writes a prescription and you take it to your local pharmacy, along with your insurance card. The pharmacist fills the prescription and you head for the checkout to pay. Depending on what medication you have had filled, you could be paying a little or quite a lot.
Why? A little known, and hardly understood, piece of the puzzle known as pharmacy benefit managers.
PBMs act as a middleman between pharmacies, manufacturers and insurance companies, often overcharging insurance programs and underpaying pharmacies, leading to higher prices for consumers.
The behind the scenes work of PBMs can make potentially lifesaving, or sustaining, medications nearly impossible for those patients who need them most.
Patients who undergo kidney transplants must take a regimen of anti-rejection medications after surgery and for some patients the monthly out of pocket cost for filling those prescriptions can total thousands of dollars. For these patients, there is no choice but to take the prescribed anti-rejection medications because not doing so means the organ will stop functioning – it is simply a life or death choice that can impact patients with limited incomes and poor coverage.
There are organizations to help patients in need, such as the Alabama Kidney Foundation (AKF), which in 2021 provided more than $1 million in education and direct assistance to patients across the state of Alabama – including accumulating copays for anti-rejection medications.
While the AKF is dedicated to reducing the financial burden for patients who cannot afford expensive copays, the question becomes, “If the cost of lifesaving prescription drugs was reduced, how could those funds currently being used to cover cost be redirected?” Perhaps monies could be used for more research or to advance technologies in organ transplants.
With little to no oversight, PBMs, which control more than two-thirds of the prescription drug market, are allowed to drive up out of pocket costs for consumers without any repercussions.
It’s time for our federal leaders to step in and demand change to the practices of PBMs, which put patients at a severe disadvantage, especially those with limited means of income.
Kidney transplant patients simply cannot go without anti-rejection medications and cost should never be a factor in access to prescriptions. Put people first and regulate PBMs for the benefit of all patients.