Crohn’s & Colitis Foundation Urges Congress To Pass Legislation to Reform Pharmacy Benefit Manager (PBM) Industry
Published: May 1, 2023
PBMs are third-party administrators contracted by health plans, large employers, and others to negotiate and buy drugs from manufacturers, distribute them to patients, and manage drug benefits for insurers and employers’ drug benefit programs. Currently the three largest PBMs — CVS Caremark, Express Scripts, and OptumRx —hold nearly 80% of the prescription benefits market in the U.S. PBMs operate with significant conflicts of interest: they may own their own mail-order pharmacies, have financial relationships with drug manufacturers, and in some cases, are owned by health insurers.
PBMs and insurers prioritize their profits over patient care and often make coverage decisions based on the financial interests of the PBM, not the best outcomes for the patient. Crohn's disease and ulcerative colitis, collectively known as IBD, are chronic diseases for which there are no cures. Biologic medications have emerged as an important IBD treatment option that can induce and extend disease remission. But, because these medications can be expensive, PBMs have aggressively taken steps to limit patient access to them by limiting formularies, requiring pre-authorization or step therapy, and making it difficult for patients to use third party co-payment assistance. In addition, behind the scenes rebates offered to PBMs from biologics manufacturers have slowed the market entry of lower-cost biosimilar medications.
Patients should be able to access the medications prescribed for their conditions without unnecessary delays or barriers. IBD patients deserve to understand why PBMs are making the decisions that they do, and whether these decisions are primarily profit-motivated or based on science and proper care. The Crohn's & Colitis Foundation endorses federal legislation to protect consumers and ensure that health insurance companies and PBMs are transparently reporting their actions. The Foundation also advocates for transparency in treatment decisions and costs by insurers and PBMs.
We urge Congress to pass legislation that will require PBMs and insurers to honor the treatment decisions made for patients by their doctors. Health insurance companies should not be permitted to use automated systems to assess the medical necessity of prescribed treatments. Additionally, medical personnel working for health insurance companies should be held accountable for their treatment decisions, and laws should allow for medical malpractice claims against them. It is imperative for PBMs to streamline and simplify all insurer decision-making processes such as pre-authorization, claims reviews, step therapy protocols, and appeals to ensure that patients do not face any unnecessary delays in treatment, which may lead to further complications. Accountability is critical to ensure that patients receive appropriate and effective healthcare.
About the Crohn’s & Colitis Foundation
The Crohn's & Colitis Foundation is the leading nonprofit organization focused on both research and patient support for inflammatory bowel disease (IBD), with the mission of curing Crohn's disease and ulcerative colitis and improving quality of life for the millions of Americans living with IBD. The Foundation’s work is dramatically accelerating the research process, while also providing extensive educational and support resources for patients and their families, medical professionals, and the public. For more information, visit crohnscolitisfoundation.org, call 888-694-8872, or email [email protected].
Crohn's & Colitis Foundation
The Crohn's & Colitis Foundation is a non-profit, volunteer-fueled organization dedicated to finding the cures for Crohn's disease and ulcerative colitis, and to improving the quality of life of children and adults affected by these diseases. It was founded in 1967 by Irwin M. and Suzanne Rosenthal, William D. and Shelby Modell, and Henry D. Janowitz, M.D.