For over three years Tennessee has had Pharmacy Benefits Manager reform legislation on the books since it was passed by their legislature and signed by the governor in 2021. Such a happily ever after story for Tennessee sounds like a fairy tale in comparison to the grim situation on the ground in Alabama where folks are living through a PBM nightmare that is dredging up all the worst aspects of our state's history and framing in high relief the dystopian corporatist nightmare that it has mutated into. While legislators in Tennessee stood up for their constituents and passed laws to protect them from predatory PBMs three years ago, in Alabama the PBMs are running wild with wanton disregard for life and limb under the protection of the downtown Birmingham medical mafia kingpins at Blue Cross Blue Shield of Alabama who pull the puppet strings of the marionettes that they own lock, stock and barrel in the state house.
Fatalism, apathy and nihilism have reached terminal levels in the poisoned the minds of Alabama's citizenry to the point where people are either part of the problem and profiting off of the corruption themselves or they are so stupefied by television and beer that they have sunk into a low information coma in which they will die before they ever wake up and smell the Waffle House coffee. It does not have to be like this. It is not like this just a few hours away in Tennessee. But it is like this in Alabama because there are obscenely wealthy robber barons living in absurdly opulent Birmingham enclaves from which they dictate a self interested money lusting agenda to their craven cronies in Montgomery.
Who will be the few, the proud to stand up against this plutocratic goliath and demand protection for our independent pharmacies and the humble patients whom they serve? Passing PBM reform legislation in Alabama will be an uphill battle with BCBSAL cynically taking a knee to run out the clock as independent pharmacies suffocate to death and go out of business every day while an on the take do nothing legislature ponders whether they will address the topic with the 2025 legislative session this coming February based on the recommendations of a phony "study group" tasked with "analyzing the situation". Don't expect any aid or comfort from the bought off Alabama presstitute media who are all in the tank for and on the payroll of the downtown Birmingham corporate oligarchs. You, dear reader, are the one who will right this ship by making yourself privy to the critical knowledge included herein and sharing it with your family and friends.
BCBSAL would be well served to familiarize themselves with a variation of the Pottery Barn rule; you break Alabama, you own it. Because they most certainly have broken Alabama's healthcare system and with the depraved collusion of their downtown Birmingham cohort, they own every inch of Alabama's failure. Anyone who possesses the temerity to tell you with a straight face that the healthcare system in Alabama is not broken is a damned liar. Every one of the other forty-nine states know that Alabama is a disgrace when it comes to healthcare. What they don't know is that BCBSAL are the ones who are 1000% responsible for this shameful state of affairs.
As if any further humiliating proof was needed that Alabama is the laughing stock of the nation when it comes to healthcare, U.S. News and World Report just this week published a new article on the most obese counties in the country. Guess where #1 is located?
For the record, the other six Alabama counties that made the list were Sumter, Macon, Wilcox, Bullock, Greene and Perry. Alabama continuing to be a national embarrassment when it comes to key metrics such as healthcare and education truly is proof positive that the lunatics in Birmingham really are running this asylum. So how did Tennessee get this all so right and Alabama got it so wrong?
Answering that question to a great degree is an article in the The Tennessean published just under a year ago that really laid it all out on the line.
Out-of-pocket drug costs are rising across the nation, and many Tennesseans struggle to afford their prescription medications.
Patients and their local pharmacies are increasingly under attack by multibillion-dollar corporate middlemen called pharmacy benefit managers (PBMs), which are third party administrators that manage prescription drug formularies on behalf of insurance companies.
Although PBMs were created to control prescription drug prices, they now exert tremendous control over which medications Tennesseans can receive, where to get them, and how much they cost. And unfortunately, most people don’t even know they exist.
Pharmacy benefit managers put profits ahead of patients
In 2022, Tennessee adopted Public Chapter 1070 to help regulate PBMs by establishing fair contracting and pharmacy audit protections; ensuring patients can use the pharmacy of their choice; and establishing increased transparency and fair reimbursement for medication costs. All are important measures to help patients and pharmacists alike.
Additionally, the Federal Trade Commission (FTC) recently launched a formal study into PBMs to investigate and “scrutinize the impact of vertically integrated pharmacy benefit managers on the access and affordability of prescription drugs.” Since the study’s launch, the organization unanimously voted to issue a statement withdrawing its previous advocacy statements for PBMs, remarking that those statements “no longer reflect current market realities.”
The Tennessee Pharmacists Association (TPA), the only professional association representing pharmacists across the state, has been working tirelessly to ensure PBMs follow the new law and are held accountable for the harm they pose to patients and pharmacies. As part of their efforts, they have been instrumental in offering legislative leadership perspectives to the PBM issue in Tennessee and have shared valuable insights and ramifications with the FTC’s recent investigation.
Since they’ve been historically unregulated, PBMs, specifically the three largest – CVS/Caremark, OptumRx, and Express Scripts, have gained enormous market share through unfair and anti-competitive business practices that put pharmacies and the patients they serve at risk. Something needed to be done and I commend our legislators for acting.
Although the PBMs were originally created to help manage drug costs, their focus has instead become finding new and hidden ways to increase the cost of medicines for their own benefit. The drug pricing system involves an extremely complex process on which few patients, providers, and legislators are educated, and which allows PBMs to increase profits at the expense of patients with limited repercussions.
PBMs routinely put profits before patients and the pharmacists that serve them.
How you can take control of your relationship with the pharmacist
To help protect Tennesseans’ health and wallets, here are four common PBM tactics patients and employers should look for, along with how best to combat them:
PBMs limit prescription medication options on their “formulary”:
According to the PBM Accountability Project, PBMs excluded 846 drugs from their formularies in 2020. PBMs often remove low-cost generic prescriptions covered by insurance and instead steer patients to higher priced medications. Patients should contact their local pharmacist directly to verify which prescriptions are available and discuss the best and lowest priced alternatives.
PBMs require you to use PBM-owned pharmacies:
PBMs often steer patients to their own mail-order pharmacy at the risk of the patient facing higher copay amounts for their medications. Under the new law, PBMs cannot restrict a patient's choice in which local pharmacy they patronize. Instead, patients can choose the pharmacy that they know and trust, especially when that pharmacy is located closest to their home. If your ability to choose your own pharmacy is being infringed upon, contact the Tennessee Department of Commerce and Insurance to file a complaint at: www.tn.gov/commerce/insurance/pbm/complaint.
PBMs use the “spread pricing” or “claw back” method:
Spread pricing occurs when PBMs charge health plans higher prices than what they reimburse to the pharmacy, leading to higher costs for the plan sponsor and increased premiums and copays for patients. If the copay is higher than the ultimate reimbursement to the pharmacy, PBMs “claws back” the excess copay from the pharmacy and keep it as a profit. Employers should review reimbursement data to ensure PBMs are delivering on their contractual obligations. PBMs are not allowed to reimburse pharmacies less than the actual cost.
PBMs attempt to collect additional fees:
PBMs often line their pockets by charging increased or new fees directly from manufacturers. These fees are often hidden from health plans and patients. Employers should have their health plan showcase how their PBM is passing these savings back to your company.
HELL YEAH!