Scenarios like this happen every single day at independent pharmacies, rarely do we get to see both sides of the coin and see where the money actually went. I will outline this claim for you so you can see where the money goes.
Pharmacy X purchases a drug for $5.70, they submit this cost to the PBM for a particular patient, the PBM says we’ll pay you $4.01. The PBM then turns to the insurance company (BCBS of TN in this scenario) and tells them there was a claim for a drug and the insurer must pay the PBM $109.17.
So, the pharmacy purchased the drug, checked drug interactions and appropriateness, labeled, dispensed and counseled the patient all for a loss of $1.69. The insurance company paid $109.17 – much more than they needed to pay. The PBM stands in the middle lying to both parties and pockets $105.16.
If you had eliminated the PBM, the pharmacy could have charged a total of $19.70 which would have covered the cost of the drug ($5.70), the cost to dispense ($7.00) and a professional fee ($7.00) for their service and it would have saved the insurer $89.47. This is all just on one prescription – think of the millions of prescriptions where PBMs are involved - that can add up real fast.
The rising cost of healthcare (on the drug side) has nothing to do with the cost of drugs or evil insurance companies driving up rates – it is the PBMs. They are the middlemen sucking away money from struggling businesses and cash-strapped patients proving no good or service at either end of the spectrum.
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Encourage Governor Cuomo to pass the PBM Reform Bill