It is understandable that there needs to be a balance between medication cost and preferred access availability. At face value (no pun intended), it seems intuitive that pharmaceutical companies can simply lower the price of medications, make their products more accessible, and procure a reasonable profit by increasing their volume of sales. In fact, a large piece of the medication cost is due to the percentage that PBMs require to be paid in order for a product to be accessible, especially on a preferred list. For example, if a new topical medication for acne or rosacea is priced “too low”, the percent that goes to the PBM is not attractive enough to them. Ultimately, the PBM can select coverage based on their own financial interest. Therefore, the PBM is in the ultimate position of power to make decisions on medication access, and we are at the mercy of how they weigh the different factors that influence their choice.
In addition, to further discourage prescribing of certain products, PBMs and third-party insurers establish tiers that place paperwork burdens on physician offices in order to apply for medication access. These burdens include the prior authorizations, appeal letters, and “peer-to-peer” phone calls that drain a lot of the time and energy of ourselves and our staff. As clinicians, we face these additional challenges in the crevices of time between trying to see our patients and provide the best care for them. Unfortunately, the puppet master who is “the man behind the curtain” that is controlling the strings are remote individuals at PBMs and third-party offices who remain faceless and far removed from the clinicians and the patients.
Most recently, I was informed that one of the major PBMs did not offer any topical agent that is FDA-approved for treatment of persistent facial erythema of rosacea in a preferred status category. I conferred with their medical director about this and provided a through explanation of the disease state with supporting scientific references. The reply I received stated that their review committee evaluates available therapies and that if I wanted one of the FDA-approved agents that I can apply through their prior authorization process. They are fully aware that if they overburden our office staff with cumbersome paperwork and bureaucracy that they will