PBM ExpressScripts, CareMark, Humana, OptumRX

Bruce KneelandI read a social media post recently that linked to an article by a physician complaining about large pharmacy benefit managers (PBMs). What made this article worth mentioning is that it was published in a journal whose readers are primary care physicians. It’s nice to know we aren’t fighting this battle alone.

The actual article is lost in old LinkedIn posts and can’t be found. But no worries, the author said little that ComputerTalk readers do not already know. However, the author did share a couple of statistics that I found interesting. First, even though there are 66 PBMs, the largest three serve approximately 89% of the market, according to a post from the Center for Insurance Policy and Research updated on April 11, 2022.

While not included in the article, I am told that most of the smaller PBMs do what a PBM is supposed to do: validate patient eligibility, process claims, negotiate better prices for payers, and reimburse pharmacies in an equitable manner.

In September 2019, I wrote an article for a prominent pharmacy publication about how one smaller PBM worked with a pharmacy owner to get the school board in the pharmacy’s area to switch to a smaller but more pharmacy-friendly PBM. The pharmacy owner involved in the process was on the school board and reported that the change resulted in saving the school district about a half-million dollars. He also said reimbursements to pharmacies in the community were significantly improved.

Pharmacy-Friendly PBM

So what’s the point? Just this: the people, processes, and companies are already in place to solve many of the problems pharmacies have with the large PBMs. What’s needed is for more companies to choose one of these more pharmacy-friendly PBMs.

One way to make this happen is to invite the hundreds of companies that sell to pharmacies to look into the advantages of contracting with one of the smaller PBMs. The best way I know for that to happen is for those reading this article to start asking the companies they buy from which PBM they use for their employee benefits. It would be great if pharmacy organizations, both state and national, joined the effort by encouraging their corporate members to do the same.

Imagine what would happen if pharmacy owners started including in their vendor selection process the question “what PBM does your company use?” Then imagine what would happen if a few supplier companies started including in their marketing materials a statement like this: “XYZ Company Is Proud to Contract With a Pharmacy-Friendly PBM.”

The National Community Pharmacists Association (NCPA) publishes a list of independent/transparent PBMs. These PBMs have pledged to conduct business in accordance with a set of guiding principles developed by NCPA that align the interests of patients, employers, and community pharmacies.

You Can Access The List Here

Of course, we need to recognize that for a supplier company to make this kind of switch is complicated. Frequently, when a company selects a health insurance plan, it is then left to the healthcare plan provider to select a PBM. Thus, the employer may not be able to switch. But there are self-insured companies that exist where making that change is less complicated. Even when it is not practical for a pharmacy vendor to engineer the switch, the fact that they are asking the question will prove useful. Doing so will force the healthcare plan provider to look more carefully at the PBM providers they choose.

No one idea, strategy, or tactic is the final answer to the PBM problem. Political action and legal challenges are the central part of a winning strategy. But it just seems to me that the idea of pharmacists asking their suppliers to join in the fight is one more tool we can use to solve the problem.

Vendors need to know that what PBM they choose just might help them win more business. The bottom line is this — we need help in fighting this battle. It seems to me that one good way to make that happen is to ask for help from the companies that sell to, and are dependent upon, retail pharmacy.

I’d love to know what you think. Email me at BFKneeland@gmail.com. CT


p class=”CT-body ParaOverride-35″>Bruce Kneeland is an independent pharmacy veteran, author, and podcaster. He can be reached at BFKneeland@gmail.com and listened to at www.pharmacycrossroads.com.



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