Health News

Have you ever wondered why your prescription costs what it does? Why the same medication might be $15 at one pharmacy and $45 at another? Or why your insurance suddenly stopped covering a drug you’ve been taking for years? The answer, more often than not, involves three letters: PBM.

PBM stands for Pharmacy Benefit Manager, and these companies have more control over your prescription drug costs than most patients realize. As a pharmacist who deals with PBMs every single day at Walker Pharmacy, I want to pull back the curtain on how this system works – because understanding it is the first step to navigating it.

What PBMs Actually Do

Pharmacy Benefit Managers are middlemen between drug manufacturers, insurance companies, and pharmacies. They were originally created to manage prescription drug benefits efficiently. In theory, they negotiate lower prices with manufacturers, create formularies (lists of covered drugs), process prescription claims, and set copays.

In practice, the three largest PBMs – CVS Caremark, Express Scripts, and OptumRx – control roughly 80% of the prescription drug market. They decide which drugs your insurance covers, what you pay, and how much your pharmacy gets reimbursed. That is an enormous amount of power concentrated in very few hands.

How PBMs Affect Your Prescriptions

Here are some common scenarios our patients experience that are directly tied to PBM decisions:

• Formulary changes: Your medication was covered last year but is not this year. The PBM changed the formulary, often because a competing drug manufacturer offered a larger rebate.
• Step therapy requirements: Your doctor prescribes Medication A, but your PBM requires you to try (and fail on) Medication B first. This is called step therapy, and it is driven by cost, not clinical judgment.
• Prior authorizations: Your pharmacist submits your prescription, and the PBM requires additional paperwork from your doctor before they will cover it. This can delay your medication by days.
• Steering to PBM-owned pharmacies: Some PBMs own their own mail-order pharmacies and incentivize (or require) you to use them, even if you prefer your local pharmacy.

A Pharmacist’s Perspective

I will speak plainly: the PBM system is broken, and it is hurting patients and independent pharmacies alike. I have seen PBMs reimburse our pharmacy less than what we paid for the drug, which means we lose money filling your prescription. I have seen patients forced to switch medications that were working because a PBM changed their formulary mid-year. And I have watched the prior authorization process delay critical medications for patients who needed them immediately.

There is bipartisan momentum in Congress for PBM reform, and organizations like NCPA (National Community Pharmacists Association) are fighting hard for transparency and fairness. As a patient, the most powerful thing you can do is understand the system, advocate for yourself, and choose an independent pharmacy like Walker Pharmacy where we will fight for you.

Can I do anything if my PBM denies my medication?

Yes. You have the right to appeal. Your doctor can submit a prior authorization or a formulary exception request. At Walker Pharmacy, we help facilitate this process every day and can guide you through it.

Is it cheaper to use a discount card instead of my insurance?

Sometimes, yes. We always check both options for our patients at Walker Pharmacy. If a discount card like our Walker Discount Card or GoodRx gives you a lower price than your insurance copay, we will let you know.

Why does my pharmacy get reimbursed less than what the drug costs?

This is called underwater reimbursement and it happens frequently with PBMs. The PBM sets a maximum reimbursement rate (called MAC pricing) that can be below our acquisition cost. It is one of the biggest threats to independent pharmacies nationwide.

Want a pharmacy that fights for you? Transfer your prescriptions to Walker Pharmacy today. Visit walkerpharmacy.com/transfer-prescriptions or call 912-681-3784. We accept all major insurance plans across our four Statesboro, Brooklet, and Lyons locations.

Disclaimer: This article is for informational purposes only and does not constitute legal or financial advice. Consult your insurance provider or pharmacist for questions about your specific coverage.

— Jordan Walker, PharmD | Owner, Walker Pharmacy