During the COVID-19 pandemic, pharmacy benefit managers, PBMs, have been taking real action to help patients. The pandemic has forced quick decision-making and adjustments, and PBMs have worked with members of the prescription drug and medical device supply and payment chain to get patients needed drugs, vaccinations, and tests.
At the onset of the pandemic, PBMs quickly pivoted to begin alerting patients to get early refills for their prescription drug regimens, helped patients who needed drugs that were in shortage, and ramped up mail-service pharmacy operations so patients could stay home and avoid unnecessary exposure to the virus. In addition, hand-in-hand with pharmacies, PBMs have been using their role as care coordinators to leverage available information to encourage people to get vaccinated and to make their follow-up appointments.
Most recently, PBMs have leaned into the mission of access to COVID tests, taking up the Biden Administration’s call for providing free at-home tests to consumers. The Administration’s goal is to eliminate cost-based barriers to testing, especially for lower-income Americans. This meant insurers and PBMs had to be able to connect the consumer, the insurer, and the retail outlet selling the tests. Understanding the urgency given rising case numbers, and working with health insurers, PBMs developed and put systems in place to manage these transactions in a matter of days.
The Administration’s guidance requires health insurers to make the diagnostic tests available through a health plan’s retail pharmacy network. Creating an entirely new reimbursement and delivery system is not an easy task, and the rollout has encountered some logistical issues, including tests in short supply and pharmacies learning the new systems. Beyond that, some plans and PBMs have had difficulty in getting network pharmacies to participate. As the health care system adjusts to implementing this new COVID test coverage requirement, these early kinks should be ironed out and PBMs will continue to do their work to make the process as easy and accessible as possible for pharmacies and consumers.
PBMs are also stepping up, voluntarily, to cover dispensing fees for new oral anti-viral COVID medications, which will be an increasingly important part of the national effort to adjust to endemic COVID infections. As pharmacies began figuring out the economics of dispensing government-, not pharmacy-, purchased drugs, PBMs began discussing with the Administration voluntarily paying dispensing fees for these drugs, which are not technically covered by Medicare and other insurance. Pharmacy dispensing fees are normally outlined in network contracts and are typically set at market rates. In this instance, most PBMs are paying standard or Medicaid level dispensing fees in an effort to help pharmacies be able to administer these drugs and, in turn, to help patients access them.
Pharmacists could play an even larger role in helping people quickly access anti-virals, but right now, the FDA emergency use authorization for these drugs specifies that essentially only a physician can write a prescription for them. This adds a step as patients may need to make three separate stops — a test center, a physician’s office, and a pharmacy — to eventually receive a medication that must be started in a timely manner. Should the Administration amend the labeled use of these drugs, pharmacists could then administer COVID tests, read results, order these drugs, and dispense them, all in one location as a one-stop-shop.
We urge the Administration to use its regulatory authority to streamline the prescribing and dispensing process for COVID tests and medications.
PBMs continue to work with all of the stakeholders in the prescription drug supply and payment chain to iron out these logistical challenges. The most important consideration, by far, is helping Americans get the tests and treatments they need and deserve to handle this pandemic.
