Pharmacies v manufacturers

In this episode, Darshan Kulkarni speaks with Dae Lee about the growing conflict between pharmaceutical manufacturers and pharmacy benefit managers (PBMs) — and how it’s reshaping the U.S. drug supply chain.

They unpack the recent dispute involving AstraZeneca, which alleges discrepancies between the number of branded claims submitted by pharmacies through PBMs and the rebates invoiced by those PBMs. The issue shines a spotlight on how PBMs control formulary access and drug distribution, often requiring manufacturers to pay hefty rebates to ensure their products are covered — a “pay-to-play” model that impacts pharmacies, patients, and drug pricing transparency.

Dae explains how PBMs, through vertically integrated structures and rebate aggregators, dominate prescription benefit management, often retaining portions of rebates meant for plan sponsors. Manufacturers like AstraZeneca, meanwhile, face limited visibility into claims data and have no direct contractual relationship with dispensing pharmacies — making it difficult to reconcile payments or validate rebates.

The conversation also delves into the consequences for independent pharmacies, who are subject to increasing audits, lower reimbursements, and complex purchasing requirements dictated by PBMs. While eliminating PBMs altogether may be unrealistic, both Darshan and Dae agree that growing regulatory scrutiny and transparency reforms could help rebalance the system.

Takeaway: PBMs’ influence reaches every corner of the prescription drug market. For pharmacies and manufacturers alike, maintaining strong records, understanding rebate structures, and preparing for evolving regulations are essential steps toward fairer and more transparent operations.