how the PBM industry affects the price you pay at the pharmacy counter

     This is just one example of how the PBM/insurance industry affects the price you pay at the pharmacy counter. This is not one isolated example. Think why diabetics are paying “out the nose” for copay on their insulin.  Back when I started working in pharmacies – as a pharmacy student – there was no U-100 insulin but a u-40 and u-80… but if u-100 would have been available … its price would have been around $2.50 for a 10 ml vial.

Today, Insulin can run $300 AND UP for a 10 ml vial.

Recently Lilly brought out a “generic insulin” at a lower price and upon its release, Lilly stated that there would be no rebates/discounts/kickbacks paid to the  PBM/insurance industry collectively responded ” NON-COVERED ITEM”

In the example above, the GROSS PROFIT DOLLARS for the wholesaler and pharmacy is about 20% of what the PBM/Insurance industry makes on this single transaction, and the both of those entities (wholesaler/pharmacy) has to have stock on hand to meet the needs of the pt..  as opposed to the PBM/Insurance industry which has only personnel, computers and buildings.

Some would argue that the PBM/insurance industry really provides little/no actually healthcare and when you consider that they are in charge of which medications that they will pay for, how many doses a pt can get a day and how long they can have the therapy… the could actually have a NEGATIVE IMPACT… because of their need to have days or weeks to get around to approving a prior authorization that they have imposed.

Just look at the numbers the wholesaler – in this particular example – is expected to remain profitable on a 3%-4% Gross profit margin and the pharmacy is expected to do the same on a 5% gross profit margin. Compared to Walmart works on abt a 25% gross profit margin on their overall operation.

Whereas, the insurance/PBM industry their GROSS REVENUE is their GROSS PROFIT… since they do not provide any products and have no inventory of products.  In this particular example the PBM/insurance industry collects almost 50% of the dollars that the pt ends up paying for the medication.

So who is the “real robber” when the pt pays a lot of $$$ to have a prescription filled ?

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