Learn about Pharmacy Benefit Managers (PBM) practices and profits in this infographic. Did you know that today, the top three PBM’s, CVS Caremark, Express Scripts and OptumRx control 85% of the market? PBM’s generate revenue involving billing health plans for amounts higher than they reimburse pharmacies, creating a “pharmacy spread”. PBM’s impose “direct and indirect renumeration” (DIR) fees on pharmacies, imposed after sale in a manner that is not readily predictable.
Imposing “gag clauses” prevents pharmacists from informing consumers about the availability of lower cost options. In order to have the drugs they produce included on PBM formularies, manufacturers often increase the cost of the prescription drugs to pay considerable rebates and fees to the PBMs. PBMs also hold leverage over prescription decisions due to their involvement in pre-authorization requirements.
In a traditional model a PBM might contract with a retail pharmacy chain such as CVS at AWP-18% and then offer a contract discount of AWP-17%, keeping the difference for themself. The only rebates that a PBM typically shares are the performance rebates. Access rebates are paid from drug manufacturers to PBMs for listing and keeping their brand drug on the preferred formulary.