Sjögren’s is a systemic autoimmune disease that affects the entire body. Many patients require ongoing prescription therapies for symptom control and prevention of complications, so stable, affordable access is essential. This becomes increasingly important as new drugs for Sjögren’s come to market. The policy information that follows explains pharmacy benefit manager (PBM) reforms and the concrete steps lawmakers can take to make treatments more affordable and accessible for people living with Sjögren’s.
Congress is actively considering bipartisan legislation to reform how PBMs operate that has led to soaring drug costs for patients.
What are PBMs?
PBMs are companies that help health plans manage prescription drug benefits. They negotiate prices and rebates with drug manufacturers, decide which medicines are on plan lists (formularies), and set certain rules for coverage.
How Do You Interact with PBMs?
Whether you have Medicare Part D or private insurance, health plans use formularies, prior authorization, health plans have tools in place that determine what you pay and how quickly you can access them.
PBM policies and payment arrange can influence which medicines are covered, the steps to obtain them, and the costs at the pharmacy counter.
Why Are Reforms Needed to PBMs?
As new drugs come to market for Sjögren’s disease, patients need clear, affordable, and timely access without unnecessary delays or surprise costs. Today, many patients pay out-of-pocket amounts because certain drugs are not widely covered, or that are based on prices that don’t reflect the discounts PBMs negotiate.
How PBM Reforms Help You?
For people living with Sjögren’s, PBM reforms aim to lower your costs and speed access to the medicines your clinician prescribes. If Congress passes bipartisan reforms, it will mean patients will have stronger access to more affordable medications to manage this disease.
The Foundation is working with partners to urge Congress to pass these bipartisan reforms.