If you’ve ever had trouble getting a prescription drug, chances are you’ve encountered a pharmacy benefit manager.
These companies, known as PBMs, play a critical but often hidden role in deciding which drugs you can get and how much you’ll have to pay personally. They are intermediaries in the highly complex American health care system, working on behalf of your employer or government insurance programs like Medicare, which cover most of the cost of prescription drugs.
The PBM’s job is to save you money on your drugs. But the New York Times found that the three biggest PBMs often make you pay more than you should.
Here’s what you need to know about your PBM and how to find out if you’re being overcharged.
How do I know which PBM I have?
Most Americans rely on one of the big three PBMs: CVS Caremark, Express Scripts or Optum Rx. Even if you own a smaller PBM like Prime Therapeutics, you may be affected by the business practices of the three giants. (This is because many smaller PBMs outsource some of their dealings with drug companies and pharmacies to their larger competitors.)
This is different from health insurance that covers your doctors visits or hospital stays. While you can usually choose your health plan during your employer’s open enrollment period each year, your PBM is chosen for you.
You usually get an ID card in the mail that shows which PBM you have. Or you may need to ask your employer’s HR department.
If you’re on Medicare, you can choose an insurance plan each year, but the government website that lets you compare plans doesn’t specify which PBM is affiliated with which plan. You may be mailed an ID that identifies your PBM, or you can try calling your Medicare plan.
What does my PBM do?
Your PBM affects you most directly by choosing the drugs your insurance will cover and deciding how much you’ll pay out-of-pocket for them.
The PBM comes up with a list of covered drugs, known as formularies. It also decides which medicines to encourage you to take, making them cheaper for you. It discourages you from taking other medicines by making them more expensive or creating barriers such as asking you to try other medicines first. Your insurer or employer signs off on the PBM’s recommendations.
Is my PBM overcharging me?
If the cost of your drug is high, it can be difficult to tell which factor in the health care system is to blame. Sometimes, it can be your employer or insurance company’s fault, not your PBM, because they offer skimpy benefits. However, there are many common scenarios where the PBM’s business practices are the main reason you’re paying too much.
PBMs sometimes force patients to take a brand-name drug even though a cheaper generic version is available. If you’re paying a lot for a brand-name drug, ask your doctor or pharmacist if there’s a cheaper alternative you could switch to.
Even when you get a generic, your PBM may charge you more than it would if you paid for it yourself—without using insurance—at your local pharmacy or an online pharmacy. This is often the case with generic drugs for chronic conditions such as cancer or multiple sclerosis.
Check out options to pay out of pocket for your drug instead of using your insurance. These include GoodRx, which lists prices at pharmacies near you, or Mark Cuban Cost Plus Drugs Company, an online pharmacy that sells hundreds of drugs.
Who can help me?
A good rule of thumb: Talk to your pharmacist.
“Meet them. Know the pharmacist’s name and make sure they know your name,” said Stephen Giroux, an independent pharmacist in upstate New York who is an outspoken critic of PBMs. “We know what the prices are. We can suggest lower cost alternatives.”
Pharmacists are among the few professionals in the system with a clear perspective on how PBMs are forcing patients to pay more. Often, they can step in on your behalf if the PBM asks you to pay more than you should. For example, your pharmacist may suggest you waive your insurance to get a lower price or point you to a manufacturer’s coupon that could save you money.
If you have drugs mailed from a pharmacy affiliated with your PBM — such as Accredo, which is owned by the same company as Express Scripts — it’s worth visiting your local pharmacy to see what options you have.
If you have a large bill for a drug that you can’t afford, you can also ask your pharmacy if you can pay over time.
Can I switch PBMs?
It depends.
If you have insurance through your employer, you can’t change PBMs, but you can complain to your employer. Start by talking to HR. In many cases, employee complaints about the high costs they face for a particular drug are the only way the employer finds out there is a problem.
If you’re on Medicare and want to change PBMs, you can choose a new plan for next year. You should do some research to make sure you are actually choosing a different PBM, since many Medicare plans use the same PBMs
Because you have so many choices with Medicare plans, the best advice is to focus on what you can learn about a plan’s benefits, the drugs it covers, and how much you’ll pay for specific drugs each month. All this information is on the Medicare website.
