The reason, health researchers and industry officials say, is the very companies that are supposed to keep a lid on drug spending can maximize their profits by marking up the prices. Other companies in the drug-supply chain won’t stop them, because consolidation has swept many of the businesses under the same parent.
#Cigna, #CVS and #UnitedHealth said that the prices they charge for drugs varies by pharmacy and location, and that most patients end up paying less out-of-pocket through their insurance than they would buying the drugs at lower cash prices offered by low-cost pharmacies.
The companies own the three largest #pharmacy-benefit_managers in the U.S. PBMs manage drug spending for employers as well as government programs.
In the name of keeping down drug costs, PBMs decide which medicines a patient’s health plan will pay for and how much the patient will have to contribute to the cost, in the form of out-of-pocket expenses like #deductibles and coinsurance.
PBMs also often direct patients to take lower-priced, generic versions of expensive brand-name medicines to limit the spending.
Generics are a cornerstone of American efforts to tackle high drug costs. Once patents on the branded drugs expire, generic manufacturers can jump in. The competition usually causes prices to plummet.
Yet the prices don’t always fall when PBMs own their own pharmacies. And for specialty drugs like generic Gleevec, the PBMs frequently steer patients to use their in-house pharmacies to fill prescriptions.
PBMs try to pay as little as possible for drugs distributed through independent retail pharmacies. But when their own pharmacies dispense prescriptions, PBMs profit from the higher prices.
“The incentive is there for the PBMs and the specialty pharmacies to keep prices as high as possible,” said Shannon Ambrose, co-founder and chief operating officer at Archimedes, a company that competes with PBMs to manage specialty drug spending.
Even when their health insurance picks up most of the cost of a drug, patients can face a larger expense from higher priced generics if they have an out-of-pocket contribution like a deductible or coinsurance pegged to the price.