Pharmacy Benefit Managers at Odds with Specialty Pharmacies Save

Reuters and the Wall Street Journal have reported that the largest U.S. pharmacy benefit managers (PBM) of private prescription drug benefits have cut off at least eight pharmacies that work closely with drugmakers, intensifying scrutiny of a system that helps inflate drug prices. (WSJ source: http://buff.ly/1X1aVUO)

The terminations come from payers who together manage drug benefits for more than 100 million Americans. This follows disclosures by Valeant Pharmaceuticals International Inc in late October that one pharmacy accounted for about 7 percent of its sales. Express Scripts, OptumRx, and CVS Health have lodged complaints and some, lawsuits. 

Independent pharmacies and their drugmaker partners counter that Express Scripts, CVS and OptumRx together control more than two-thirds of the market through their own mail-order operations. The specialty pharmacies say that the benefit managers are trying to curb the explosive growth of smaller, independent players.

It is estimated the number of specialy pharmacies has risen to a total of 250 in 2015. Specialty pharmacies were first formed in the 1970s to deliver products requiring special handling to doctors' offices and hospitals, including therapies for cancer, HIV/AIDS or hemophilia. The field has evolved to include mail-order operations that offer services for complex, high-cost drugs, often for rare or chronic diseases - there is no action against "specialty" pharmacies that help manage drugs for rare diseases.

The focus on such relationships is part of a broader debate over drug costs—and an increasingly high-profile cat-and-mouse game between PBMs and drug makers over what, and how, medications will be paid for by insurance.