Pharmacy benefit managers are the part of health care many patients love to hate. They help decide which medicines a plan covers, negotiate prices with drug makers, and build the network of pharmacies a patient is allowed to use. When that machinery works, nobody notices. When it doesn't, patients notice very quickly. The latest episode of the State of the Patient podcast looks at both sides, starting with a story where it worked.
Lu Ann describes herself as a caregiver, and calls it the hardest title she has. In 2021, her mother, who has lived with rheumatoid arthritis for more than 45 years, developed a serious infection that had to be cleared at home before surgery was possible. Her Medicare Advantage plan's PBM assigned a specialty pharmacy four counties away. That pharmacy packed every shipment for the weather, called every other day to check how many supplies were left, and when shipping couldn't make the deadline, put someone in a car to drive the medicine to her. "I didn't call anybody," she says on the episode. "They called me."
The episode is just as direct about the patients for whom the pharmacy benefit has become a part-time job, especially around prior authorization. PCMA's president and CEO, David Marin, acknowledged at a Patients Rising town hall that the association has not been the partner many people need it to be, including patients. Brendan Buck, PCMA's chief communications officer, described the industry's push toward electronic prior authorization, which PCMA says brings approval down to an average of about five and a half hours, though only when a doctor's office uses those systems.
The most practical part of the conversation is about timing. Real-time benefit tools let a doctor see, during the visit, what a plan covers, what a medicine will cost and whether a lower-cost option would work as well. Buck encouraged patients to ask for that check before a prescription is sent. The episode also covers TrumpRx, the administration's cash-price website: PCMA's member companies have agreed, working with the Centers for Medicare and Medicaid Services, to show its prices alongside plan prices in their tools. Buck noted that the plan price will usually still be the better deal. And because a cash purchase may not count toward a deductible, it pays to compare both.
Finally, it helps to know who your PBM is and who it works for. As PCMA's Lucia Lebens explained, a PBM's clients are employers, unions and government programs, so a benefits office can be asked why a medicine is covered the way it is.
Listen to the full episode and read the transcript: [EPISODE PAGE LINK]
Read Patients Rising's PBM Policy Deep Dive: [DEEP DIVE LINK]