Back to Blog

It’s Time to Address Rx Access Restrictions

By California Chronic Care Coalition

June 28, 2021

By Liz Helms
President & CEO
California Chronic Care Coalition

Over the past several months, we’ve seen improvements in California and across the country in our efforts to end the pandemic. Nearly 20 million residents of our state are fully vaccinated. However, it’s clear that we have ways to go, and the effects of COVID-19 will be long-lasting.

For too many in California, lack of access to affordable care will only be exacerbated in a post-COVID environment. This includes prescription medications, which are in large part controlled by pharmacy benefit managers (PBMs) – insurance middlemen that determine what drugs patients and doctors can access and, increasingly, how much they cost at the pharmacy counter.

Three PBMs control more than 80 percent of drug purchases, meaning PBMs have tremendous negotiating power in determining which treatments are available on formularies. Patients with cancer, a dermatological condition like psoriasis or atopic dermatitis, rheumatoid arthritis, or other chronic conditions are at the mercy of back-room business deals that shut out the voices of medical experts.

In recent years, PBMs have engaged in harmful business practices that restrict access and hurt patients. One practice is the use of “rebate traps” to prevent formularies from including newer and often more effective treatments for illnesses including gastroenterological conditions to heart disease to psoriatic arthritis. A “rebate wall” exists when a PBM strikes a business agreement to exclude specific medications from a drug formulary in return for a sizeable rebate that benefits the PBM at the expense of patients. A paper by the Center for Medical Economics and Innovation at the Pacific Research Institute concluded that alleviating rebate walls could save patients thousands of dollars per year in out-of-pocket costs while increasing competition and improving health.

We deserve better. If we allow this harmful practice to continue, it will hinder our ability to continue to make strides against COVID-19 and to be ready for what lies ahead. The idea that individuals can be denied life-saving medications because of a back-end business agreement is wrong and will only exacerbate the hurdles our families and communities are now facing.

Policymakers across the political spectrum are speaking out on rebate walls. During her time as a U.S. Senator, Vice President Harris joined several of her colleagues in urging the Federal Trade Commission to address the issue. The Trump Administration attempted to implement regulatory changes to end PBM rebates in Medicare and Medicaid. And, then-California Attorney General Becerra has also expressed his support for ensuring that we don’t limit access to medications.

Let My Doctors Decide, a coalition of leading patient and provider organizations, released a series of patient-centered principles with a focus on ensuring access to life-saving medicines. This includes “prohibiting contracts that use rebates and other volume discounts to ban inclusion of other treatment options from formularies.”

We look to California’s new Attorney General and other top legal officers should open an investigation into the use of rebate walls and put an end to this discriminatory practice. It’s time to change the status quo and ensure that doctors and patients make medical decisions, not insurance executives negotiating contracts, as we look to the future and continue to rebuild from COVID-19.