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.