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The nation’s top pharmacy benefit manager (PBM) lobbying group is going on the offensive, stepping up its advocacy efforts against the pharmaceutical industry after Congress passed a PBM industry overhaul last winter.
The pharmaceutical industry spent years pointing fingers at pharmacy benefit managers as the reason for high drug costs, and Congress finally was able to get PBM reforms over the finish line as part of a larger government funding bill.
David Marin, CEO of the Pharmaceutical Care Management Association (PCMA), acknowledged in an interview that the PBM industry had essentially operated in the shadows for too long.
As lawmakers focus on affordability ahead of November’s midterm elections, PBMs want to make sure they are not being left out of the discussions.
Previously, Marin said the industry wasn’t responsive to the increasing pressures for change and spent too much time fending off attacks from the pharmaceutical industry without fully explaining how PBMs fit into the larger prescription drug ecosystem.
“We want to be utterly transparent, we want to be fully understood,” Marin said. “We do not want to be opaque.”
Marin, who took the job in January, said PCMA in years past spent far too long letting pharmaceutical companies turn PBMs into the boogeyman, which made the industry ripe to be targeted for reform.
“I think it’s safe to say that for too long we were in a defensive posture, and that’s not what policymakers are looking for,” Marin said. “I think there was relentless energy from Big Pharma to shine a light on PBMs, and they were effective. It’s a complicated business and industry, and I think it took that relentless effort” for PBMs to be the bad guys.
The legislation imposed what critics said were much needed changes to the PBM industry.
It enacted new transparency reporting requirements, and banned a practice called “spread pricing” in commercial insurance plans, where a PBM charges a plan more for a medication than they reimburse the dispensing pharmacy and pockets the difference,
It also de-linked a PBM’s compensation to the list price of the medication they select for coverage, eliminating a conflict of interest where PBMs could make more money by steering patients and health plans towards more expensive drugs.
PBMs are middlemen that manage prescription drug plans for insurers and negotiate rebates and discounts with drug manufacturers. PBMs are responsible for negotiating prices with drug companies, paying pharmacies and determining which drugs patients can access and how much they cost.
They are often owned by and integrated into large insurance companies. The three biggest PBMs are UnitedHealth Group’s Optum Rx, CVS Health’s Caremark and Cigna’s Express Scripts, which represent about 80 percent of all U.S. prescriptions.
Marin, a former executive at pharmaceutical company Viatris, suggested that since Congress has acted and reforms are now law, PBMs are due for a messaging rebrand.
“We allowed others to define us, others who had a clear interest in diverting attention away from the role that they play in keeping drug prices too high for too long for too many, and they did it well. So I tip my hat to them, but we have to change that dynamic,” Marin said.
As part of that effort, PCMA recently launched a seven-figure advertising campaign, its largest ever. The group also unveiled a policy agenda focused on affordability and transparency from drugmakers.
“No amount of message discipline can change the facts. Three PBMs control 80 percent of the market, routinely deny patients the medicines they’re prescribed and ultimately decide what patients pay at the pharmacy counter,” Alex Schriver, senior vice president of public affairs at PhRMA, said in a statement to The Hill.
The battle over how to lower drug prices has been marked by finger pointing among all sides. Drugmakers blame PBMs and insurers, while those groups say pharmaceutical companies are responsible for high prices.
“I think the ads that you’ll be seeing from us are simple, they’re focused on people, they’re educational, and they really just highlight the two foundational roles that PBMs play: lowering drug costs and protecting and promoting patient safety,” Marin said.
The PBM industry faced intense scrutiny on Capitol Hill last year; essentially every committee in both chambers with jurisdiction over health care drafted PBM reform legislation, and President Trump also frequently railed against them.
Pharmaceutical companies have also faced scrutiny, but after PBM regulation has near-miss in 2024, pharmaceutical companies and their allies made a concerted effort for Congress not to let PBMs off the hook.
PCMA wants to make sure lawmakers don’t try to push through any additional reforms this year, especially in the post-election lame duck period when bipartisan legislation could be considered. Senate Democrats have also keyed in on more PBM reforms if they retake control next year.
Marin noted there’s a PBM transparency rule pending in the Department of Labor, which he said is largely duplicative of Congress’s efforts and should not be implemented.
“It’s important that members sometimes be reminded of the massive reform package that they just passed. I think it’s only smart policy to allow those reforms some time to ripen and mature,” Marin said.
Updated at 4:35 p.m. EDT
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