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  • Nixon Benefits

Pharmacy, medical office, or hospital? When it comes to drug costs, location matters.

The recent lawsuit filed against Johnson & Johnson by one of their employees could expand the spotlight on PBMs to include the other channel where patients access drugs: health insurers’ provider networks.  Drugs are accessed from a pharmacy (where PBMs apply the drug pricing), but drugs are also accessed at a doctor’s office or hospital setting.  The price of the same drug can be significantly different between a pharmacy (PBM/retail) and a provider setting (hospital or doctor's office).  The cost of drugs accessed in a provider setting are controlled by the health insurer, the health insurer’s PBM, and/or the provider’s PBM.  The employer, whether paying claims or insurance premiums, is not included in provider network contracting nor providers’ drug pricing when utilizing a provider network. 

Source: National Association of Plan Advisors


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