4. Lack of Transparency and Data Access: Markets cannot function when pricing and rules are hidden.

*PBM’s are one of the few organizations that can be asked for information and tell such requestor to “take a hike” on a regular basis.  

*Rules continue to change with the PBM’s, continuing to add to the confusion and complexity in reviewing these plans and policies, as well as typically only benefiting the bottom-line of these PBM’s.

*All too commonly, plan sponsors (including employers) do not have full transparency to expenditures with the PBM’s, and end up actually over-paying for medications that are reimbursed partially with manufacturer rebates.  These rebates were designed to help reduce overall drug costs, and all-too-often end up partially or completely in the PBM’s pockets rather than the plan sponsor, pharmacy, or patient.  Patient’s typically pay high out-of-pocket expense through deductible or high-copay values, plan sponsors pay the difference plus administrative fees to PBM’s, patients pay premiums to plan sponsors to the PBM, and pharmacies often aren’t reimbursed 100% of necessary costs of medication & overhead costs. 

*A recent legal case involving a large, self-insured employer, found a court dismissed claims tied to prescription drug pricing after concluding that alleged point-of-sale overpayments did not constitute injury when viewed in the context of overall plan benefits. The court’s decision shows how PBM disputes are still being viewed through fiduciary frameworks established for other benefit types, even though drug costs are incurred in real time and directly affect patients at the pharmacy counter (through decisions to take therapy, offsetting costs of medication VS groceries or other bills, etc.). Because of this, decisions often come not from a single “right VS wrong” choice, but from being unable to document why one approach was chosen over others or how patient interests were weighed.