For Your Benefits
For Your Benefits
What's Going on with the PBMs? A Deep Dive
/

What’s Going on with the PBMs? A Deep Dive

Pharmacy benefit managers (PBMs) were created as middlemen to reduce administrative costs for insurers, validate a patient’s eligibility, administer plan benefits, and negotiate costs. But up until now, they’ve operated virtually unchecked.

The FTC recently launched an investigation into the six largest PBMs regarding their role in increasing prescription drug prices. In this episode, we talk with Catherine Hall, RN, Director of Prescription Drug Management, about what’s going on with the inquiry and how benefit advisors can protect their clients from bad PBM practices.

In this episode, we discuss:

  • The ins and outs of how PBMs work
  • Details of the FTC investigation
  • Current reform efforts, including pending legislation
  • How benefit advisors and consultants can support clients

On a recent For Your Benefits podcast episode, Catherine Hall talked to us about the effects of rising drug costs and what employers and consumers can do to control spending. To learn more, listen to Essential Strategies to Reduce Prescription Drug Costs.

In This Podcast

Catherine Hall, RN, BSN

Catherine Hall, RN has been a registered nurse for more than 40 years and has been a Registered Nurse Advocate with SentryHealth since 2014. She is also a national speaker and has been recognized by the American Heart Association for her expertise in stroke care. Catherine currently serves as Director of the Prescription Drug Management program, educating members about their medications and offering lower cost pharmacy alternatives.

Meghan Henry:
Hi, everyone. And welcome to For Your Benefits. I’m Meghan Henry, Director of Marketing at SentryHealth. In this podcast, our goal is to help benefit advisors, HR teams, and other stakeholders stay on the cutting edge of what’s happening in the world of employee health benefits.

On today’s episode, we’re excited to have Catherine Hall, Director of Prescription Drug Management here at SentryHealth back with us again. Catherine has been a registered nurse for more than 40 years and has been a nurse advocate with SentryHealth since 2014. Currently, she serves as Director of the Prescription Drug Management Program, educating our members about their medications and sourcing lower cost alternatives. Thanks for joining us again, Catherine.

Catherine Hall:
Oh, great to be here. This is a very interesting and exciting title.

Meghan Henry:
Yeah, definitely. So Catherine, the last time you were here, we talked about how to lower prescription drug costs. So in the same vein, today we’re going to talk about what’s going on with these PBMs. There’s a lot of scrutiny going on right now. And with the FTC launching an investigation into the six largest PBMs regarding their role in rising drug costs, we’ve got a lot to talk about.

Catherine Hall:
Well, that is true.

Pharmacy Benefit Management: Who are they and what do they do?

Meghan Henry:
So let’s jump in. Catherine, for those who don’t know, and I suspect there are very few of them. Can you start off by explaining what a pharmacy benefit management company does and then sort of what that means for employers?

Catherine Hall:
Sure. Your pharmacy benefit manager is the one that manages your prescription drugs on behalf of your company. They manage your drug formulary, in other words, the formulary that your clients are allowed to get drugs at and what’s covered. In turn, payers give PBMs, which is the pharmacy benefit managers, money in administrative fees. They actually are paying them for the actual drug and the drug dispensing. So what started out as a pharmacy benefit manager kind of being just a person that helped you get medications has turned into almost a fiduciary for your pharmacy benefits.

Their responsibilities are to process and pay your drug claims and determine which drugs will be covered on the plan. Again, manage your formulary. They determine which pharmacies will be included in your prescription drug network. Now that’s a big one because you know we all know that we have the CVS, the Walgreens, the Targets, the Costcos, the Sam’s, the big pharmacy, but what about the “mom and pop” ones? We’ll go into that a little bit further, delving in further in my discussion. And they also determine how much the pharmacy will be paid. Now, we all think, as people who get drugs ourselves, our own prescriptions, that’s the cost of my drug.

That drug cost includes the administrative fees for the PBM, paying of the pharmacies. Every pharmacy gets a cut of your prescription drugs. As Meghan said earlier, there are six large ones, but three of the PBMs control 80% of our market. That is CVS, Express Scripts, and Optum RX. Those are the three PBMs that control 80%. That’s a lot of percent for just three companies.

Meghan Henry:
No kidding.

Catherine Hall:
This significant market share allows the PBM to exercise undue market leverage and generate outsized profits for them. In other words, CVS, obviously, the drugstore CVS, has that and they have now partnered with different insurers so if you have like, for example, Anthem, you are only allowed to go to a CVS store. You cannot buy anything at any other store. It will not be covered. And that’s again, how they generate that market leverage that everything goes to their companies. They, the PBM, have different pricing agreements with each pharmacy and they withhold the difference between the billed cost and the pharmacy reimbursement cost.

Let me give you an example of that. Your agreement says that your companies and your clients will pay $20 for a 90-day generic medication. In actuality, a 90-day supply of that medication only costs $10, but because they have a pricing agreement with those pharmacies, that pharmacist will charge you $20. The PBM pockets the other $10. That’s how they make more of their money.

Meghan Henry:
Interesting.

Catherine Hall:
They’re required to use the PBM choice of the pharmacy, which I was just talking about. And they rank the drugs on their formulary based on the rebate amount, then the lowest cost. Every drug that you have on your formulary has a rebate aspect from the manufacturer. So, whoever manufactures Eliquis gives these PBMs a rebate if they put that drug on their pharmacy going through that pharmacist. So this is a much deeper problem than we ever thought that went on with them. Just as an interesting side fact, the gross profits for those three PBMs, CVS, Express Scripts, and Optum RX were $28 billion in 2018. Those are the last stats we have. 28, not million, billion dollars by doing these rebates, by overcharging and keeping the money, et cetera.

Why did the FTC launch an investigation on PBM companies?

Meghan Henry:
So, Catherine, you’ve kind of given us the background of how all this works. And so what is happening now? This seems to be coming to a head. The FTC is launching an investigation. They’re looking into these PBM companies. What are they looking at? What are they scrutinizing?

Catherine Hall:
What they’re looking at, with the PBMs, are all the different things PBMs practice—their rebate practice, their clawback practice, their direct revenue practices.

So, we have the new Pharmacy Benefit Manager Transparency Act of 2020, which has gone through. Now, you have to understand that PBMs are not ruled, governed, reviewed, or audited by any government agency or overseeing agency. They are their own entity, so they can charge and do what they want.

Meghan Henry:
Wow.

Catherine Hall:
So, they’re looking at this, the FTC, and the government is looking into this by saying, we want to ban your unfair pricing schemes. We want to prohibit you from being able to do clawbacks. If you are unaware of what a clawback is, a clawback is a reimbursement to the pharmacy, to the PBM, months, months after the drug was purchased. They go back and look and say, oh, the company overpaid for this, so they take that money, they claw that money back. And instead of giving it back to the company, the PBMs keep it for themselves, hence $28 billion in gross revenue.

Meghan Henry:
Well, and you look at the rising prescription drug costs. Employers are paying more, the consumers are paying more. And so I think they’re looking at this going, whose fault is this? Is it the drug companies, the PBMs? Who’s got a part in all of this and how can we regulate or how can we figure out what’s going on?

Catherine Hall:
Right. And the thing is, they’re just all delving into this right now, understanding these practices that have been going on. Regarding that, there are so many things that we don’t have control over that we have to make sure that we’re aware of, and we can ask. For example, you know that a pharmacy, a pharmacist has a gag order by the PBM. They’re not allowed to tell the member upfront what the cost of that medication is unless the client asks for it. So let’s go back to that example that the pharmacist said to that patient, “Your company says you owe $20 for this medication. I know it only costs $10. I know I’m taking money from you, but I am under a gag order by the pharmacy benefit manager that if I express that to you, they will pull all their formularies from our pharmacy and we will lose revenue.”

But if the member asks, “What is the cost of this medication without my copay?” And they say “$10,” then the patient only has to pay $10. So there’s always been a misconception that the pharmacist will tell you if that price is lower, or if you don’t use your insurance, it’s better. Or if you do a 30-day or a 90-day versus a 30-day, but we are just finding out now that part of the contracts that those pharmacies—CVS, Walgreens, et cetera—sign says, it’s a gag order, you cannot discuss the price of medication unless specifically asked. So we have our $20 copay and we just think, okay, every medicine we have that is a 90-day under this category is going to cost us $20, and that’s not true.

The other thing they do is that the manufacturers, when you ask me, who’s at fault, it’s kind of everybody. The manufacturers want their drug on the formulary, so they raise the price of the cost of that medication to cover the rebate that they’re going to give that pharmacy benefit manager and therefore more out-of-pocket for our clients, more increased pay to the pharmacy company, to the PBM. So, there’s a lot of things that are going on right now, government-wise, that they want to be able to set the FTC, et cetera, wants to be able to set prescriptions prices so everybody knows a drug should cost the same, whether it’s at CVS, Walgreens, Costco, Sam’s Club, but it is not.

Meghan Henry:
And that’s interesting, Catherine, that you bring that up. So I’ll give you a real-life example of that happening. My husband and I are now of the age where colonoscopies are recommended and he recently had one. So, he had a prescription for Sutab and went to a pharmacy to have it filled, wasn’t covered by our insurance. They said, “Oh, well, we’ve got a coupon for you. We’ll knock $40 off of it.” I think he ended up paying $150. Two weeks later, I got my prescription for the same thing and I went to a different pharmacy. It was closer, no reason for me to go there, just closer and I was just being lazy. I went there, and they said, it’s not covered, but we’ve got a coupon. We’ll add your insurance. I paid $40. So, the same medication, same use, same coverage, but one pharmacy charged him $150, and the other one charged me $40.

Catherine Hall:
Exactly. And they’re doing that.

Meghan Henry:
And we had no way of knowing how that would have played out. There’s no way of knowing we should have gone to Pharmacy B instead of Pharmacy A from the get-go, would’ve never known.

Catherine Hall:
Right. And here’s another reason why that we’re told to go to CVS, or you can only go to CVS and Publix, because again, those are contracts that the PBM has made, and that’s the only place you can get your medication. Hence why there’s this wonderful little thing called GoodRx, and you can put your drug in GoodRx and the dosage, and you can put in your ZIP code, and boom, you will see 20 different prices from 20 different pharmacies. And so, the whole thing is, like I said in the beginning, PBMs are acting more like fiduciaries than they are just an ancillary person to help us.

Meghan Henry:
And Catherine, as a consumer, not to toot our own horns, but if you had something like what you do, the prescription drug management program, they could contact you and you could help them figure that out too, as well.

Catherine Hall:
Yes. I look at all aspects—I look at GoodRx, I look at domestic pharmacies where I can get medications at a lesser price for you. We have other avenues of being able to get prescription drugs for you globally. The other thing is, don’t ever forget about patient assistance. You can go in and put your drug name on the computer and ask for patient assistance. And a lot of time they’ll have a copay card that your copay maybe $90, but they’re going to tell you’re only going to pay $10.

Meghan Henry:
Yep. Yep.

What can employers do on their end?

Catherine Hall:
So those are ways to help the client, the member, and the employee. The employer needs to review their pharmacy contract and scrutinize every single word of it. That’s their responsibility to make sure that they’re not getting involved in clawbacks, rebates, or what drugs are on. Every single benefit manager, HR person, and company owner should be looking at their pharmacy reports and looking at what are my 10 top expensive drugs? And then they should be looking at that and saying, I have, and I’m just using false numbers now, I have a hundred employees. 20 of my employees are using this medication which cost over $3,000 a month. Now, they should be marketing the PBMs, on who can assist me in getting a reduced cost price for those top-cost meds. And instead, we always go with a PBM we’ve always gone with, or sometimes the PBMs are connected to different insurances like we talked about at the beginning.

And so, the most important thing that you do as an employer and an HR director is to review your formulary prior to signing the contract. They also will be able to tell you what is your gross calculation for your company, because you need to know that, all right, that drug costs $3,000 a month, times 12 months, times 20 patients. So then you start looking and saying I need these drugs incorporated into my formulary because you know what, you are hiring them. You’re paying them an administrative fee, et cetera. Pharmacy benefit managers, again, with the trade commission and other government agencies are trying to get them to work together as an ancillary part of the team.

Know your state laws and CMS guidelines to hold PBMs accountable.

So, there must be more than just a quick perusal of your contract with your pharmacy benefit manager and a signature. Become active in your legislatures, become very active in this. There are all kinds of things in each state. There are several states that are trying to, currently, right now, put different practices in place saying you can’t do this anymore to our customers. They can go to “mom and pop” pharmacies. They can do things that work best for them. And you’ve got to negotiate your contract to require adherence to state laws and CMS guidelines, which means y’all are going to have to know your state laws and your CMS guidelines. And that’s especially important for your benefit manager and advisor because that person is the one that takes care of your company, so they have to be really careful that they know what their state laws are and can hold accountable the PBM to the state laws and CMS regulations.

Ask For the Reports
The other thing you can do is to require your PBM to provide reporting of reimbursements paid to the pharmacies on pharmacies’ claims because guess what, that’s part of your money. You have every right to know what the reimbursement was going to CVS, Walgreens, Costco, Sam’s, et cetera.

So, we could talk for hours and hours and hours about PBMs and their practices. Like I said, there’s clawbacks, there’s the rebates. All of these things that the pharmacy benefit managers are doing now are causing increased costs to the company and to the employee, especially when prices are artificially raised to accommodate the rebate for the PBM. Think about the person who has to pay, on a specialty drug, 20% of the cost. Now, unfortunately, your employee is now paying for part of that rebate that goes to the PBM and they’re 20% of 3000 some dollars per month. So all of this is pushed back to the patient, pushed back to the community pharmacies, pushed back to the poor employer who’s doing his best to try to manage money and spending for his company with that.

PBMs are on the radar. The Supreme Court actually turned down looking into PBMs because they felt it was a violation of the ERISA law, which again, is a whole big thing. It’s with Medicare. But because they chose to turn that down and not investigate, that was a huge win for the PBMs. Again, remember, as we’ve said before, there is no regulating agency over them. They can charge what they want. They can recoup what they want. They can clawback what they want.

Is there legislation pending that would address PBM problems?

Meghan Henry:
So, on that note, Catherine, is there any legislation that’s pending, or is there anything going on maybe in Congress that’s looking to address these problems? Is there anyone looking to regulate this stuff?

Catherine Hall:
Exactly. Well, yes, we do have the HR Bill 4829, which is a Government Accountability Office that they’re trying to address the rebates and fees and the authorization and the step therapy. So that will help with things. There is, like I said, the Pharmacy Benefit Manager Transparency Act that is looking at all of these. They all know what the issue is, the problem is money, money, money, money.

Meghan Henry:
Yep, yep. Yep.

Catherine Hall:
So, if we say to the PBM, you can’t do more rebates, you’ve got to go back to how you were first designated as being an ancillary assistance to my company, and I paid you a small administrative fee to take care of that. They need to go back to that because of the fact that right now, pharmacy costs make up a lot of every company’s annual budget. And so what the legislation is trying to do is prohibit unfair and deceptive practices. There is a bipartisan proposal that is supported by the National Committee of Pharmacists that is looking at trying to get them to reduce their clawbacks and things like this. But again, you have to understand that as long as there is money involved, it’s going to be very difficult to change these practices.

Meghan Henry:
Absolutely. So you deal a lot with prescription drugs, you deal with the employees, you deal with the employers, you deal with the benefit advisors, trying to help everyone find the best drugs for the best costs.

Why is PBM reform important?

Meghan Henry:
Why, in your opinion, is this PBM reform so important? What is it going to do for the consumer, the employer, the benefit advisor? What are the benefits of this? I assume saving money.

Catherine Hall:
Well, yes, that would be the very first thing.

Meghan Henry:
Sure.

Catherine Hall:
If PBM, pharmacy benefit manager reform actually occurs, it will lower costs. It will reduce the amount of prior authorizations that are needed for medications. Prior authorizations really restrict doctors on how they can treat their patients. And I can speak on that. I have a medical issue that could have really been taken care of by this drug, but my pharmacy benefit manager said, no, you have to try this drug and this drug first, and then you can go to that drug.

Meghan Henry:
Hmm.

Catherine Hall:
So, if we take out that step, therapy, if we take out the prior authorization for having some drugs and getting somebody to say, yes, that is medically necessary. I think that in the long run, it’ll be easier to get pharmacies. All the pharmacies will be able to be established and you can go to any pharmacy you want to. You’ll be able to have a company formulary that does take care of the majority of your patients and you’re not having to pay exorbitant fees with this. They want to make sure that if the transparency actually happens with the PBMs, then we’ll know their utilization. Right now, we have no idea. Most of the benefit advisors and HR directors don’t know what to ask PBMs for. They don’t know that they can ask them for a list of what you have reimbursed pharmacies for, from my company’s prescriptions, because those are all hush-hush.

Meghan Henry:
Right.

Catherine Hall:
So, when you start delving into things and learning about it, they have rights. We’re basically putting our lives in the hand of a PBM that is concerned more with $28 billion than they are with allowing the communities, the employees, employers to have the medicine they need at a cost that isn’t ridiculous. There is a statistic that at any time a patient’s medication becomes greater than $250 copay, 80% of those prescriptions are never filled.

Meghan Henry:
I am not surprised by that. And I have read statistics lately that are very similar to that. And people going into debt because of prescription drugs and people who need maintenance drugs and things like that just can’t afford them.

Catherine Hall:
And so, what we’re seeing is that, yes, this drug that came out that costs a thousand dollars a month, is science-based the best drug for whatever condition is happening to your patient or your employee. So it’s not a step therapy. It is, this is the new drug that is out, but because they want you to try the others again because they don’t cost as much, they’re not considered specialty drugs. But at this point with having a prior auth and a step approach to medications, the PBM has now circumvented the doctor’s order, delayed patient care, and possibly changed the outcome of the patient’s condition. So we allow the PBMs to have that much control. We don’t have to. We can request those reports. We can look at our pharmacy. The first thing I do when a company hands me a pharmacy report is I organize it by the top 25 most expensive drugs for that company. And then I’m looking at going, oh my goodness, well, we can get this one here at this cost and this one here at this cost.

I’ve been doing the pharmacy management program here at SentryHealth, like you said, for a long time. On average, by utilizing other than PBM, companies can save anywhere from 40 to 60% on their pharmacy cost. And that is an average for every company I have looked at their pharmacy reports. But we’re going outside of the PBM—we’re getting it sent from other places, we’re utilizing coupons, we’re utilizing patient assistance, we’re utilizing free drugs from the manufacturer. So, there are multiple venues that benefit advisors can also use to get their costs down. But the goal of this would be that we don’t have any more secrets. We know exactly what these medications are going to cost; what is going to come from our annual budget for pharmacy costs.

Those clawbacks that we were talking about, you can have a wonderful pharmacy budget and think that you’re right within it and you’re doing so great. And then the pharmacy benefit manager comes back and says, oh, by the way, we’re clawing back this money because this medicine actually costs a little bit more, so we’ll take that from you now.

So you can have a wonderful budget, but unless you understand all the idiosyncrasies that PBMs can do to get extra money, again, not regulated by anybody, it’s just somebody that says, oh, this looks like a good idea.

Meghan Henry:
Yep. Yeah.

Catherine Hall:
And so, any company that would like to have a little bit of a step-by-step on what can be done to assist them. Number one, you need to get a pharmacy report. I cannot tell you how many times I’ve heard an HR manager say to me, “Oh, Blue Cross Blue Shield, Cigna, whatever, they don’t give me a pharmacy report.” They have to. You’re paying for it. You’re the one doing this, so that’s inexcusable and that’s laziness on that PBMs aspect. And it’s also because they don’t want you to know how much they’re spending on their drugs. You have a right.

Meghan Henry:
And when you know, you can make decisions. You can request things, you then have power with that knowledge, the leverage with those PBMs.

Catherine Hall:
Exactly. And you have an opportunity, not just the PBMs, but for your own employees. If I know that my benefit structure is set up that they’re going to pay $20 for a 90-day generic, $60 for a 90-day brand, $120 for off-formula brand. But specialty drugs, they’re going to pay 20% of the cost. Now they go back to their pharmacy reports and say, do I want my employee to pay this every single month they get their med. They’re not going to afford it. You’re going to lose out on your employee and it’s just not good for your whole company. You have the right to look at a pharmacy report to understand what you’re spending. If you don’t understand what you’re spending, please get a hold of SentryHealth, who will let you get a hold of me. I’ll be glad to explain what you’re spending every month; because if you get a true pharmacy benefit report from them, I can explain to you where all your costs are going every month.

And do you want your employees, who are paying 20% not to have their drug so that they can get better and be productive for your company and be a valued member? So again, there are morals, there are ethics, there are just rights and wrongs that the PBMs over all of this time have just decided to say, there’s nobody telling us what we can and cannot do. Guess what, we’re going to do this.

What can benefit advisors do to protect their clients?

Meghan Henry:
And I think for benefit advisors, so they’ve got all these employer clients and their job is to help advise their clients on the best decisions for them, for their employees. So I think, particularly for the benefit advisors who are helping with these PBM contracts and things, knowing where the money is being spent by each of their clients, that absolutely gives them great insight into PBM company selection, contracts, things like that. And they can even, among their clients, compare and contrast and get so much information just by having those reports and being able to look across their client base. Who’s spending what on what, and how can I move Company A to what Company B is doing, because we’re seeing great results with that PBM or whatever that might be.

Catherine Hall:
Well, and when you look at your pharmacy reports and you say, why is this person still getting brand when there’s a generic.

Meghan Henry:
Right.

Catherine Hall:
Because, and if you don’t know that, again, because I don’t expect every benefit advisor and HR director to be well versed in every drug known out there to man. Again, which is why I said, if you have issues, contact SentryHealth, because there are ways that we can assist you. But you’re right, they have a right to know this. They should be able to discern what’s going on and make the best decisions based on their employees, not the PBM.

Meghan Henry:
Right. What other things can benefit advisors do to protect their clients?

Catherine Hall:
Well, and again, as we talked about on my last podcast with it, generic, anytime you can do generic, it’s going to be better. Always make sure that you instruct and teach your employees to check their formulary for a medication. Because there may be, I’ve done this with my doc. I said, “Doc, do you realize this drug’s going to cost me for a 90-day supply, it’s going to cost me $8,000?” And he’s like, “What?” Do not think that your doctor knows the cost of medication. They do not. And I said, “So you’re telling me this is the only drug.” And he goes, “No, no, no. Let’s try this one before we spend that kind of money.” You got to be open and communicative with your doctor and look at that, knowing what’s on your formulary and discussing it with your doctor if there are any alternatives. And again, as we talked about the benefit advisors, just please, know your formulary. Please, please know that prior to signing the contract.

Meghan Henry:
And I think it goes along with you saying to have those reports if you know what the employees or what your client’s employees are using, the high-cost drugs, perhaps a different PBM with a different formulary is going to save that employer money. Being able to have that data, you can shop around.

Catherine Hall:
Exactly.

Meghan Henry:
And it would benefit both the employer and the employees as well.

Catherine Hall:
Well, and again, as we’ve talked, we want to make sure that PBMs cannot manipulate the healthcare system anymore, which is what they’re doing.

Your benefit advisors, if they’re not reviewing anything, they’re unaware of the actual cost of the medicine. People are going to be very surprised when they see the actual cost of the medicine is this, and by the time it gets to your employee it costs this. This is information every benefit advisor and HR director can get. They just have to sometimes beg for it, which they shouldn’t have to. And the benefit advisors are actually, they’re unaware of maximizing their value through the PBM. They don’t understand, they have empowerment. And the other thing is, what we have right now, is the PBM “take it or leave it” contract. You either take what I tell you we’re going to do or leave it. Well, if enough of us said, “leave it,” guess what, it would change.

Meghan Henry:
Yeah.

Catherine Hall:
But because, again, PBMs are not under any regulatory agency of any kind, then they can give you a “take it or leave it” type contract.

Meghan Henry:
I think that also allows the opportunity for the advisors to shop around. So I know at the beginning you had mentioned that some of the biggest companies sort of held onto the biggest market share.

Catherine Hall:
Correct.

Meghan Henry:
But there are several PBMs out there, so I think it always is a good opportunity to take that data, leverage that data, and look around, shop around to the different PBMs. And I would also assume that one PBM may not be the best for every one of your clients, so really taking a close look at that employee population for each client and then trying to make it fit. They’ve got different formularies, they’ve got different payment rates and all of that stuff. And so looking at which of these PBMs is the right fit for each client, as opposed to assuming CVS for everyone, or Walgreens for everyone, whatever that is.

Catherine Hall:
Right. And so it’s very frustrating because you know that you can get this drug when you call around. We don’t go and get a car at the first place we go to. We’re online, we’re shopping, we’re looking at the things we want, the best price we want. What’s this? We do this for just about everything in our life, except pharmacy.

Meghan Henry:
It’s difficult to be a consumer.

And be an educated consumer. And even from a client perspective, from an employer perspective, being educated on that when the data and when the pricing information and when all of that stuff isn’t clear, and it’s not apparent, and it’s not right in front of you. It’s difficult, I would think, from me, from an employee patient consumer perspective, but I would say even as an HR person or as a benefit advisor, not having that clear transparency on how all of those things work and what’s going on behind the scenes with these rebates and things. And you’ve got to just work within the system and that’s kind of what you’re doing. In your current role, you’re taking advantage of the fact. In an ideal world, you wouldn’t have to be here to do these things because it would all be fair. It would be fair, it would be transparent, and it would be equal for everyone. It’s not currently.

Catherine Hall:
Right.

Meghan Henry:
Which is why you do what you do. And then hopefully with this reform, some of this gets changed.

Do other countries have PBMs?

Right. And the other little tidbit of information on PBMs is, that we are the only country in the world that has them. No other country has PBMs. Hence why you can buy medications in other countries much less expensive than you can in the United States, because they don’t have that middleman that’s doing the clawbacks, the DIRs, and everything else. We are the only country in the world that has PBMs.

Meghan Henry:
Well there you have it.

Catherine Hall:
And again, that came again because everything is money.

Meghan Henry:
Yep. Catherine, before we wrap up, do you have any last piece of advice for benefit advisors or HR managers, stakeholders, and sort of what you recommend? What’s the number one thing, maybe if they’re leaving this podcast today, what do you want them to leave with?

Catherine Hall:
I guess the biggest thing is, to ask for your pharmacy report. It’s yours, you pay for it. And second of all, beyond everything, remember who you’re fighting for. They’re your employees. It’s not big pharma. It’s not the PBM. It’s not even the insurance company. It’s your employees. So again, know your pharmacy report. Look at that. Talk with different PBMs. Find out what your top drugs are. Again, I will offer that if there are questions about this, please get a hold of SentryHealth, because we’ll be glad to assist you in different ways to explain how to do that better, to review a pharmacy report with you. But you have to be the knight in shining armor for your employees. Get on the horse, put up your sword, and get your pharmacy report and know what’s going on.

Meghan Henry:
Well, Catherine, I really appreciate you joining us today. That is great information and great advice. And I know that you and I will likely be chatting again in the future once we find out what the FTC says about all of this stuff. So I want to thank you for joining today’s episode of For Your Benefits. Once again, we really appreciate you.

Catherine Hall:
Thank you very much. It was a pleasure.

Meghan Henry:
Absolutely. Thanks to everyone else for joining us today, too. If you like what you heard, don’t forget to subscribe to our podcast, For Your Benefits. If you want to learn more about SentryHealth, if you’d like to learn about the prescription drug management program that we have mentioned, please visit our website at www.sentryhealth.com. Have a fantastic day. And we hope to see you guys next time.

LET’S CONNECT

Want to learn more about SentryHealth? Simply fill out this form to request a consultation and learn more about our solutions.