I have only been at the PBM for a month. I am not Mr. Pro-PBM quite yet. I do have an understanding of how things work that I did not have before I started. I do not buy into the argument that PBM's save enough money to justify thier existence. However, I don't think they cost the system any more money. The plan sponsors would be paying the same amount of money with or without the PBM. Since the PBM is the middleman money that would have gone to the pharmacy now goes to the PBM to pay for managing the benefit. I have a huge problem with that being a former retail pharmacist. I think the major insurance companies could manage the prescription benefit just fine and not cost as much as having PBMs do it..
To answer your question, yes I think we are doing what is right for the patient and what is right for the plan sponsor who is picking up the tab. The PBM is not about denying a patient their medication. The PBM is about controlling costs based on parameters selected by the plan sponsor when they signed up for the benefit. If a plan sponsors employees were allowed to get whatever medication they wanted for any reason or no reason at all the cost of the benefit would be so high that it would have to be discontinued.
Should everyone who sees the commercial for the purple pill be allowed to march into thier doctor's office and demand a prescription for it because sometimes when they eat Mexican food right before bed they get a little heart burn? Should a plan sponsor have to pay for everyone of thier employees who wants to do this? Or does it make sense to have a checks and balance system in place that limits a patient from getting the purple pill unless they actually have a documented medical reason for it and have failed the less expensive generic alternatives first. Thats what the PBM does for a plan sponsor and how they keep the cost of the benefit dfown for them.
Z, you are a hospital man. How important is cost control in the hospital? Do you order whatever you want without regard to cost? Why should it be any different in the retail setting?
