If Medicare pursued the same strategy that pharmacy benefit managers use to weed out certain medicines and offer alternatives for private health plans, the federal government could have saved nearly $3 billion from 2012 and 2015, according to a recent analysis.
How so? Well, pharmacy benefit managers purportedly try to limit costs for private health plans by excluding certain medicines from their formularies, or lists of drugs for which reimbursement is available. But as the authors of the JAMA Internal Medicine research letter note, the extent to which such maneuvers are used by all Medicare Part D plan administrators is unknown.
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While the study has merit on it’s face, there is another reality. The current (2018) Part D plans do have formularies that are pushing generics or , more properly, excluding branded drugs to some extent. Then you have to consider the pushback against interfering with ‘doctor-patient.’
How much of this spend is already PBM managed for the subscribers? An additional factor to consider.
The PBMs so not always aggressively pursue generic alternatives there are numerous examples where generic drugs are not covered long after initial launch because of rebates offered to PBMs from the originator companies