Here’s a sentence that has been true for millennia: Change is coming. In pharmacy, for the next six months to two years, this could be truer than ever as laws and regulations come into effect that could benefit the profession. Some expected changes have been long sought for, while others are of more recent vintage. Many will come through new or modified state and federal legislation or regulations.
But what policy changes might be nearer rather than further off and how will they affect the practice of pharmacy? We’ve narrowed it down to four areas of change and then asked some experts what to expect.
1. PBM Transparency Rule Changes
Pharmacists have been complaining fora long time that PBMs do not reimburse them fairly, and state legislatures are starting to take notice, says Allie Jo Shipman, PharmD, MBA, associate director for state government affairs at NCPA.
Many states have passed legislation related to transparency on the part of PBMs. Fair pharmacy audit legislation, which allows state regulatory agencies to audit PBMs for information on what drugs cost compared to the reimbursement to pharmacies, has passed in about 40 states, Shipman notes. Greater transparency would help retail pharmacies understand reimbursement policies and rates. “One big trend that we saw come up this year especially is trends in transparency and disclosure reporting, especially for state Medicaid agencies.” Kentucky, Georgia, and Louisiana are among states that are requiring PBMs to release information on drug pricing and reimbursement rates to pharmacies as it relates to Medicaid or other state health benefit plans.
One catalyst triggering lawmakers to act on PBM transparency was CVS Caremark’s move last year to cut reimbursement rates for drugs in several states, Shipman says. “It is finally starting to come to a head where state legislators have been hearing from pharmacists and from [pharmacy] associations about PBMs and these practices,” she says.
Arkansas is the first state to pass a law to fully authorize its insurance commissioner to regulate PBMs. The law permits the state insurance commissioner to review and approve PBM compensation programs to ensure that reimbursement for prescriptions is fair and reasonable, says Jason Rapert, a Republican state senator in Arkansas, who is also president of the National Council of Insurance Legislators. The council, made up primarily of state legislators, creates model versions of laws that can be used to draft legislation. The organization has drafted a template, “Pharmacy Benefits Manager Licensure and Regulation Model Act,” that states can tailor to their needs.
“[PBMs] have been getting away with making up their own rules, playing their own version of street ball here, and nobody’s calling foul,” says Rapert. “We need a referee that can actually operate in this arena,” he tells Drug Topics. The goal of the law is to “pull back the curtain” and see what is going on in PBMs, he says. Pharmacists across the country, who have commented on the draft.
Giving states more oversight to PBM operations does not always require new legislation, Shipman notes. Some states, like Pennsylvania and Montana, are having their auditors general look more closely at PBMs, she says. “Even if they haven’t passed legislation, they are still looking at PBMs with greater scrutiny.”