PBMs Are Stacking the Deck Against Patients and Independent Physician Practices

[Duaine]

I often hear my patients ask the same questions: Why do I need to change to another infusible biosimilar again? Why do I need to get my infusion therapy sent by a specialty pharmacy? Will I be able to continue my therapy on time?

The answers are not straightforward. The story begins in 2016 when the first biosimilaropens in a new tab or window came to market in the U.S. Biosimilars are near identical copies of the original therapy with the same active ingredient, mechanism of action, and risks -- but they cost less. They are made to be interchangeable with the original therapy. While this sounds reasonable at face value, the issue stems from onerous requirements implemented by insurance companies and pharmacy benefit managers (PBMs) mandating use of very specific "preferred" therapies. I've seen the consequences firsthand at my community practice that provides infusion services.

My patient Savannah* is a classic example. She has ulcerative colitis, a chronic condition that causes inflammation in her colon. It took quite a bit of time until we found her the appropriate infusion therapy and dosing schedule to get her into remission and feeling well. Savannah's insurer subsequently required her to change to another biosimilar. However, the required prior authorization was repeatedly denied, which delayed her therapy and risked disease recurrence.

 

[somarco]

Is there a link to this or are you posting about one of your clients?

Does "Savannah" have a managed care plan? Is the medication self injected, received in a doctors office or infusion center?



There seems to be a similar article on The Hill from 2018.

Would you be willing to take part in a high-stakes card game where one player at the table can see every other player’s cards?

You might as well play with a blindfold on. When your opponent holds all the cards, sees all, knows all and controls all, you’re going to lose.

That’s the situation for millions of Medicare Part D patients and their families, as well as the physicians and pharmacists who work with them. The deck is stacked against them all, because pharmacy benefit managers hold all the cards — and they control the game.

https://thehill.com/opinion/healthcare/367407-patients-not-pbms-should-decide-which-pharmacy-they-use/

For patients in Part D plans, the price they pay for a prescription at the pharmacy counter is directed by their Part D plan’s pharmacy benefit manager and is often based on an amount that is higher than that which the pharmacy is being reimbursed for the same prescription.