In the June 26, 2018 blog post, “What is a fair share? Pharmacy middlemen made $223.7M from Ohio Medicaid” I challenged plan sponsors to not be distracted by large AWP discounts or substantial gains from guaranteed rebate dollars.
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Instead, I argued, it is more important to understand the cost of your PBM service or how much you pay the PBM for the services it provides. This fee is hidden in your final plan cost and is not the administrative fee! It is the savings (less a reasonable administrative fee) the non-fiduciary PBM negotiated on your behalf but did not pass all of it back to you.
For the first time Ohio Medicaid did exactly that and what it discovered was enough to terminate their PBM contracts with Optum and CVS Health. The department on Tuesday directed Ohio’s managed care plans to terminate contracts with pharmacy benefit managers, or PBMs, based on the “spread pricing” practice, The Columbus Dispatch reported. The state said it’s moving to a more transparent pass-through pricing model Jan. 1.
Under that model, PBMs would receive administrative fees and must bill the state the same amount they pay pharmacists. “The black box will effectively be eliminated,” said Patrick Stephan, the department’s director of managed care. A state-commissioned report showed PBMs billed taxpayers $223.7 million more for prescription drugs in a year than they reimbursed pharmacies to fill those prescriptions.
