Numerous influential corporations are eliminating numerous medications from their insurance coverage, and they are investing substantial amounts of money to thwart any efforts aimed at bringing about reform.
Having a health insurance plan that covers prescription drugs is crucial for the millions of Americans who rely on medication. The drug formulary, which is the list of covered medications, can determine whether patients pay a small copay or have to pay thousands of dollars out-of-pocket for their vital medications.
However, many patients are unaware that insurers can change their drug coverage throughout the year, which means that medications they were promised may no longer be covered. Unfortunately, when this happens, patients are often unable to switch to a different insurance plan immediately. This problem has become increasingly common, with the number of medications being eliminated from insurance plans rising by a staggering 1,584 percent in the last nine years.
Pharmacy benefit managers (PBMs) are responsible for dictating the drug formularies. These powerful companies negotiate with pharmaceutical manufacturers on behalf of health insurers, Medicaid Part D drug plans, employers, and other healthcare payers. The three largest PBMs are owned by major health insurance companies, leading to concerns among healthcare experts about potential conflicts of interest that could result in higher drug prices and lower quality care for patients.
Furthermore, PBMs have a financial incentive to prioritize drugs that generate the most profit for them, rather than focusing on the most effective and affordable options for patients. In a letter to the Federal Trade Commission (FTC), Kashyap Patel, the past president of the Community Oncology Alliance, highlighted the concerns about the PBM model and its consolidation with health insurers, stating that PBMs are motivated solely by profitability.
As lawmakers at both the state and federal levels work towards reforming the drug coverage system, PBMs are actively lobbying to protect their interests. This year, the Pharmaceutical Care Management Association, the lobbying group representing PBMs, has been particularly active in advocating for their position.
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