02/10/2025
I post a lot of links to stories about Pharmacy Benefit Managers. This one is a long read, but it’s the story in my own words and is personal.
My destiny as a community pharmacist was decided before my birth. Following in the footsteps of the three generations ahead of me, my life’s work as a pharmacist has been to treat my patients and community as my family and care for them as if they were my own. I'd like to think I've been successful at that and would like to continue for years to come.
The whole pharmacy industry has changed so much in the past few years, and not for the better. I always thought I could compete with better patient care and customer service, but it’s not a level-enough playing field. A very real and clear monopoly exists where 3 companies control over 80% of the prescriptions filled in the US. One of them is CVS Caremark, who owns Aetna (an insurance company), CVS Pharmacies, and Caremark (a Pharmacy Benefit Manager). As a result of a lack of regulatory oversight and corporate greed, my reimbursements are determined by my direct competition. Over 65% of the prescriptions I fill every day are reimbursed below my cost. Yes, you read that correctly. I had to stop stocking many brand name medications and send my patients elsewhere. For example, on Medicare Part D plan, if I fill a 90-day supply of Eliquis (a life-saving blood thinner) I’ll be reimbursed $311 less than my actual purchase price. All the while there is plenty of proof that the Pharmacy Benefit Manager is charging that Plan Sponsor substantially more than I am being paid and pocketing the difference (known as spread pricing). I am forced to fill brand name medications at a higher cost to the patient AND to the plan, than filling a generic drug that might cost 10% of the brand drug because of the “rebate” that the PBM gets from the manufacturer to keep that brand name drug on formulary. They keep those rebates from you, from me, and from your plan/employer (which sometimes means from Medicare or Medicaid which our tax dollars fund)! The PBMs are allowed to steer my patients to their own pharmacies (including mail order) and pay themselves substantially more in reimbursements than they pay me for the same services and there is no transparency or oversight. Indeed, there is no way to challenge any of this because everything is done behind curtains and mirrors, under cloak and dagger. I am subjected to predatory audits. I am subjected to "take it or leave it" contracts. Most contracts don’t even include a dispensing or professional fee. If they do, it might be $2. Do you know that pharmacists are required by law to professionally counsel you on your prescriptions but are forced by contract to do so for free? What other healthcare professional is not allowed payment for their services? The abuses go on and on.
I am relying on State and Federal legislators to finally pass meaningful legislation to turn this situation around. PBM’s have finally caught the scrutiny of the Federal Trade Commission and the heat is turning up. Mainstream media outlets are finally picking up on the story, unfortunately it has taken people dying at the hands of PBMs to catch enough attention. 2024 was a brutal year for pharmacies and we survived but not unscathed. Nationwide, an independent pharmacy closed every day of the year. In Iowa alone, there were 29 closures and more will come. What needs to happen is PBM Reform. Right now. This minute. In the meantime, I'm just stubborn and strong-willed enough to continue to fight but need everyone’s help. I am beyond grateful for the support of each and every Customer/Patient/Friend/Family I have. For those that I have let down or had to let go, I am truly sorry. Some really tough decisions had to be made because so much remains beyond my control. I am determined that 2025 will be a better year. Together with your support and my amazing staff, we will survive!
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The Problem: The Solution: Pass PBM Reform in Iowa The Solution: Pass PBM Reform in Iowa Learn More Your local pharmacy serves a critical need in your community. But pharmacy benefit managers (PBMs) are standing in the way of pharmacy access, while inflating drug prices. It
