NIAGARA FALLS, N.Y. (WIVB) — The NYS Department of Financial Services has proposed regulating a pharmaceutical middleman, known as a Pharmacy Benefit Manager (PBM) and the public comment period goes until Monday, Oct. 16.
PBMs impact many people who need prescriptions.
They were originally designed to help save Americans money on health care.
But the owner of Niagara Apothecary, Jamie Latko, said her job has gotten harder due to them.
“They’ve evolved from being a company that processed claims, into a billion dollar corporation who’s getting money from everybody,” Latko said.
PBMs are contracted by health insurance plans or large employers to help negotiate costs and payments between drug makers, pharmacies and the insurance plan.
“There’s three that dominate 80% of the market, which is CVS Caremark, Express Scripts and Optum Rx,” Latko said.
They can help choose what meds insurances will pay for, and are allowed to tell the consumer what pharmacy to go to, or even force the consumer to get prescriptions by mail-order. And Latko said mail-order prescriptions can take longer than if you visited a local pharmacy.
“If it’s an in-stock item, (it will take us) 20 minutes,” she said. “If it’s something we have to order, 24-48 hours but certainly if the patient is in need, we always, in the pharmacy community, we figure something out for that patient. It’s quick. Mail order could be two weeks or more.”
Latko said PBMs charge pharmacies fees on how they’re performing as well, and sometimes those fees are charged months after a prescription is filled.
“So I could dispense a medication today, and in 6-7 months I could lose $100 on that prescription.”
And those fees have gone up… a lot. According to Centers for Medicare and Medicaid Services, they’ve increased 107,400% between 2010-2020.
“How is that even possible?” Latko asked.
Lisa Goodman is a former customer at Niagara Apothecary. She told News 4, she was forced to go to a big-chain pharmacy, which is owned by the same company as her PBM.
“Jamie knows me inside and out, all of my health issues: my drug interactions, my allergies, and I could call her anytime if I had questions,” Goodman said.
Goodman is on about a dozen medications. A few months ago, she was told the medicine she wanted for debilitating migraines wasn’t covered by her insurance. But an alternative medication was covered.
“It was $75 a month for one shot… a self injection,” she said. “So I tried it for the first two months, and it didn’t do anything. My migraines were worse, I was suffering. So then I called my PA and said, ‘this isn’t working, can we try something else,’ and she said, unfortunately, based on the rules that my insurance has implemented, I had to wait six months.”
Goodman and Latko are both in favor of regulations on PBMs.
But the Pharmaceutical Care Management Association (PCMA), which represents PBMs, says state regulations would overstep authority.
The PCMA touts a 2022 study, which found PBMs save taxpayers $53 billion a year.
An assistant vice president of the group sent News 4 the following statement:
“The Department of Financial Services is overstepping its authority by issuing a proposal that greatly exceeds the scope of the underlying statute. As a result, the misguided proposed rule threatens to significantly increase prescription drug costs for New Yorkers while also restricting the valued option of convenient home delivery for medications. The proposed rule should be scrapped entirely or risk harmful health care outcomes for New Yorkers.” — Greg Lopes, Assistant Vice President, Strategic Communications, PCMA.
To contact The Department of Financial Services, email: email@example.com