Deborah D. Gordon has spent her career trying to level the playing field for healthcare consumers. She is co-founder of, the premiere membership organization for independent advocates. She is the author of "The Health Care Consumer's Manifesto: How to Get the Most for Your Money," based on consumer research she conducted as a senior fellow in the Harvard Kennedy School's Mossavar-Rahmani Center for Business and Government.
PBMs also negotiate drug prices with drug makers and pharmacies, decide what patient copayments or other costs should apply, and set rules for access to specific drugs. PBMs sometimes manage specialty or mail-order pharmacies that health plan members are encouraged to use. If the health plan denies your request, you usually have the right to appeal. The plan has to give you information about how to file an appeal. Again, your HCP or their office may help. The appeal may include more details from you and/or your HCP about why the medicine is necessary for you. Your HCP may need to show how the treatment fits within standard treatment guidelines, or why you need something different.
Specific drugs may also be considered “preferred” or “non-preferred,” which may influence how much the drug costs you and how easy it is to get. The PDL should include these designations, if applicable.
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