If you've ever had trouble getting a prescription drug, chances are you've come across a pharmacy benefits manager.
These companies, known as PBMs, play a crucial but often hidden role in deciding which drugs you can get and how much you will personally pay. They are middlemen in America's maddeningly complex healthcare system, working on behalf of employers or government insurance programs like Medicare, which covers most prescription drug costs.
The PBM's job is to save money on drugs. But the New York Times found that the three largest PBMs often overcharge you.
Here's what to know about your PBM and how to find out if you're being overcharged.
How do I know which PBM I have?
Most Americans rely on one of the big three PBMs: CVS Caremark, Express Scripts, or Optum Rx. Even if you have a smaller PBM like Prime Therapeutics, you may be affected by the business practices of the big three. (That's because many smaller PBMs delegate some of their relationships with drug companies and pharmacies to their larger competitors.)
This is different from health insurance that covers doctor visits or hospital stays. While you can typically choose your health plan each year during your employer's open enrollment period, your PBM is chosen for you.
You typically receive an ID card in the mail showing which PBM you have. Or you may need to ask your employer's human resources department.
If you're enrolled in Medicare, you can choose an insurance plan each year, but the government website that lets you compare plans doesn't identify which PBM is linked to which plan. You may be mailed an ID card that identifies your PBM, or you can try calling your Medicare plan.
What does my PBM do?
Your PBM influences you more directly by choosing the drugs that will be covered by your insurance and deciding how much you will pay out of pocket for them.
The PBM presents a list of covered drugs, known as a formulary. It also decides which medications it will encourage you to take by making them cheaper for you. It discourages you from taking other drugs by making them more expensive or by erecting barriers such as requiring you to try other drugs first. Your insurer or employer approves the PBM's recommendations.
Is my PBM overcharging me?
If your out-of-pocket costs for your medications seem high, it can be difficult to tell which player in the healthcare system is to blame. Sometimes, your employer or insurance company may be to blame, not your PBM, because they offer stingy benefits. But there are several common scenarios in which the PBM's business practices are the main reason you're paying too much.
PBMs sometimes force patients to take a brand-name drug even if a cheaper generic version is available. If you're paying a lot for a brand-name drug, ask your doctor or pharmacist if there's a cheaper alternative you could switch to.
Even when you're taking a generic, your PBM may force you to pay more than it would cost if you paid for it with your own money — not using insurance — at your local pharmacy or an online pharmacy. This often happens with generic drugs for chronic conditions such as cancer or multiple sclerosis.
Learn about options for paying for your medication out of pocket, instead of using your insurance. These include GoodRx, which lists prices at pharmacies near you, or Mark Cuban Cost Plus Drugs Company, an online pharmacy that sells hundreds of medications.
Who can help me?
A good rule of thumb: Talk to your pharmacist.
“Get to know them. Find out the pharmacist's name and make sure they know your name,” said Stephen Giroux, an independent pharmacist in New York state who is a vocal critic of PBMs. “We know what the prices are. We can suggest low-cost alternatives.”
Pharmacists are among the few professionals in the system with a clear vision of how PBMs trick patients into paying more. They can often intervene on your behalf if your PBM asks you to pay more than you owe. For example, your pharmacist may suggest you give up insurance to get a lower price or point you to a manufacturer coupon that could save you money.
If you have medications mailed from a pharmacy affiliated with your PBM, such as Accredo, which is part of the same company as Express Scripts, it may still be worth visiting your local pharmacy to see what options you have.
If you have a high bill for a drug that you can't afford, you can also ask your pharmacy if you can pay over time.
Can I edit PBMs?
Depends.
If you have insurance through your employer, you cannot switch PBMs but you can file a claim with your employer. Start by talking to HR. In many cases, complaints from workers about the high costs they face for a particular drug are the only way the employer finds out there is a problem.
If you are enrolled in Medicare and want to change PBMs, you can choose a new plan for next year. You will have to do some research to make sure you actually choose a different PBM, as many Medicare plans use the same PBMs
Because you have so many choices with Medicare plans, the best advice is to focus on what you can find out about a plan's benefits, the drugs it covers, and how much you'll pay for specific drugs each month. All this information can be found on the Medicare website.