Specialty drugs: The new arena for pharmacy benefit manager profits?

Could a pair of studies this week change the national conversation — and legal ramifications — surrounding pharmacy benefit managers?

In Ohio, several other states and a recent U.S. Senate hearing, much of the focus has burrowed into the “traditional” model of PBM finances: spread pricing. That simply means these drug middlemen give pharmacies less money than the PBMs themselves get from health insurers — ultimately, taxpayers’ money in Ohio Medicaid’s case.

But the new research points to a different moneymaking tactic by the PBMs: specialty drugs, which are often expensive — and potentially lucrative.

One example of a specialty drug: the generic form of Gleevec, known as Imatinib Mesylate, a drug used to treat leukemia.

Here’s how it all works:

The PBMs, such as CVS Caremark, generally determine which medications are defined as “specialty drugs.” And at least sometimes the PBMs also declare that a “specialty pharmacy” must hand out the drugs.

The rub is that these specialty pharmacies are often run by the PBMs’ parent companies, such as CVS’ retail and mail-order operation.

So in these instances, the PBMs essentially are sending money that insurers/taxpayers are paying for the specialty drugs right back into the PBMs’ own company.

More here

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