The Problem
When patients go to an independent pharmacy, the pharmacy is reimbursed by the PBM representing the patient’s insurance company. However, the largest PBMs (OptumRx, Express Scripts, and CVS Caremark) all have their own mail-order or retail pharmacies, and PBMs will often offer different reimbursement rates for those drugs than they offer to their own pharmacies. This puts the independent pharmacy at an unfair disadvantage, and as a result many prescriptions are unprofitable for independent pharmacies to fulfill, and many struggle to stay in business.
The Solution
To avoid conflicts of interest and ensure a level playing field between independent and PBM-owned or affiliated pharmacies, PBMs should be required to offer the same reimbursement rates to nonaffiliated pharmacies as they do to their own.
Model Legislation
Oklahoma’s 2019 Patient’s Right to Pharmacy Choice Act includes provisions that prohibit PBMs from reimbursing independent pharmacies differently than they reimburse PBM-owned or affiliated pharmacies.[1]
Notes
[1] Okla. Stat. tit. 36, § 6962(B)(3).