Madelaine Feldman, MD: The Role of PBMs in Controlling Patient Access

In an interview with HCPLive, Madelaine A Feldman, MD, FACR, discusses the role of pharmacy benefit managers (PBMs), how they influence patient access to medications, and the specific challenges patients face regarding treatment access due to PBM policies and practices.

PBMs date back to the 1960s when insurance companies began covering medications, moving beyond doctor visits and hospitalizations. Originally, PBMs primarily focused on processing and paying claims and establishing lists of covered medications and, in the beginning, most drugs were covered. However, as medication costs rose, formularies, or lists of covered drugs, were created by PBMs.

“Initially, when formularies were established and emphasized the use of generic drugs as the first line of treatment, it seemed to work well,” stated Feldman. “Over the years, we've all become accustomed to this approach, prioritizing the least expensive generic drugs. However, the way formularies are currently structured, especially from the perspective of a rheumatologist like myself who treats patients with conditions like rheumatoid arthritis, psoriatic arthritis, lupus, scleroderma, and other autoimmune diseases, presents challenges.”

Step therapy and non-medical switching are 2 of the major obstacles preventing patients from accessing the medications they need, and PBMs are the ones making these decisions. They also play a significant role in the access to biosimilars, with their preference for highly rebated products over lower-cost biosimilar options.

“They decide which drugs patients can take and in what order, but it's not necessarily based on clinical guidelines or standardized rules,” Feldman explained. “Even within the same insurance company, formularies can vary significantly. Additionally, PBMs dictate how and where patients receive their medications, sometimes mandating mail-order delivery, which isn't convenient for everyone, especially if a drug requires refrigeration.”

These issues, whether they result in unavailability of the desired drug, the requirement to retry a previously failed medication, or excessive cost-sharing by the patient, all lead to delays in receiving care.

This article was edited for clarity.

Feldman is president of the Coalition of State Rheumatology Organizations, chair of the Alliance for Safe Biologic Medicines, and a member of the Alliance for Patient Access.