pharmacy benefit managers refusing to pay high drug prices

editorial in the NY Times today (see http://www.nytimes.com/2014/06/25/opinion/refusals-to-pay-high-drug-prices.html?ref=todayspaper&_r=0) notes the ability of pharmacy benefit managers, through their economic power with millions of customers, in fighting the high cost of meds. in general, Express Scripts, et al, are not covering very expensive meds (eg, Advair, Victoza, some cancer meds, etc) because of their high cost, and that this non-coverage has led to dramatic decreases in US drug sales (up to 30% range). the number of excluded drugs is increasing dramatically. as the editorial notes, the problem here is that it is the pharmacy benefit managers choosing which drugs to exclude, and not clinicians, which could block patients from getting needed meds.


so, interesting editorial. to me, the issue is who is making the decision about these meds and what power they have. the best scenario to me would be to have a single payor system which would thereby have huge bargaining power (eg, the UK has negotiated a price for the hep c drug sofosbuvir at 1/2 the US price), with a clinical organization making decisions about which medications should be covered (eg, NICE, or natl institute for health and care excellence, in the UK). otherwise, cost alone tends to rule, yet again leaving us in primary care fighting with prior approvals etc to try to get meds covered when clinically needed (prior approvals might be needed in the UK type system, but would tend to be more clinically driven).