Is The Best PBM No PBM?

Recently a  Texas employer changed their Pharmacy Benefit Manager (PBM) as recommended by their insurance consultant.  The employer’s Risk Manager, one of the best there is in our opinion, tracked the claims prior to the change in PBM and after the change was made. In the first month under the new PBM, Rx claims increased more than 50%.

Something was amiss mused the Risk Manager. A meeting with a local mom and pop pharmacy to “compare notes” proved informative. In going line by line over the Rx claim report, and comparing off the pharmacy’s own computer generated Rx sales records, lining up dates, times, patient names, Rx dispensed, produced troubling news.

“Bill, spread pricing was apparant. One drug dispensed, for example, was charged to our Plan in the amount of about $138. The pharmacy was paid about $10. So the PBM kept a profit on that one drug of about $128!”

When the PBM was notified that their costs were out of line and that they needed to offer a reasonable explanation of why Rx costs increase by 53% in the first month of the program, they responded with an offer. “We will discount August’s bill by 12% and will credit next month’s bill by the same amount.”

The local pharmacist ask the Risk Manager “Why are you using a PBM? All a PBM does is screw you and me and drive costs up. I would be willing to work directly with your employer and save you money.

Editor’s Note: A Texas based TPA informed us that those clients of theirs that do not use a PBM have Rx costs much lower than those that do. Those groups cover Rx the old fashioned way; patients pay for their Rx at point of sale with cash, then file a claim with the TPA for reimbursement. Rx claims costs average 50% or more below than that of those groups that employ a PBM. Maybe the best PBM is no PBM at all?