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Pharmacy tech Morgan Gaspard fills a prescription for a customer, Saturday, March 28, 2020, at the Bocage Pharmacy in Baton Rouge, La.

After an unprecedented year focused on health and the burdens of unexpected health care costs, we must make simple changes to the complex drug pricing system to lower patient out-of-pocket costs. Proper management of chronic diseases doesn’t just help save and extend lives — it helps reduce health care costs.

To address rising prescription drug costs, one answer may be simpler than we think: Pharmacy Benefit Managers (PBMs). PBMs find themselves in the middle of many health issues, preventing innovation while being a major driver of prescription drug costs.

PBMs are middlemen, for-profit corporations that manage prescription drug benefits on behalf of health insurers, Medicare Part D drug plans, large employers, and other payers. PBMs determine many things — from the order of medications a patient must take before being able to access the medication their doctor originally prescribed (known as step therapy, or fail first) to the patient cost share through copays and co-insurance. This control can have a severe impact on a patient’s access to medication and can limit an independent pharmacy’s ability to serve patients.

How are the preferred drugs selected by the PBM for their formulary? We would like to think that it is the safety and efficacy of the medication. Unfortunately, it is more often based on how successful the PBM is in negotiating rebates and fees provided by biopharmaceutical companies. While annual rebates and price concessions to PBMs have exceeded $150 billion in recent years, the PBMs have not shared these savings with patients in out-of-pocket prescription costs.

We must provide relief for patients at the pharmacy counter and restore the shared decision-making between provider and patient. One of the first places we should look to fix the system is the role of pharmacy benefit managers in determining what we all pay and why.


president, Coalition of State Rheumatology Organizations

New Orleans