What States are Doing to Regulate Pharmacy Benefit Managers


In a poster presented at the 2024 American Pharmacists Association Annual Meeting and Exposition, researchers assessed state-level regulations for PBMs.

Exploring literature, legislation, and several other documents regarding pharmacy benefit managers, researchers found various state-by-state guidelines meant to ameliorate the predatory practices of PBMs and offered insight into how states can work together to enforce these guidelines.1

Researchers examined legislative documents, administrative codes, and regulatory guidelines catered to PBMs to stunt practices that do not benefit the self-interests of patients, providers, and payers.

Key Takeaways

  • Researchers presented their findings on state-level PBM regulations.
  • While various legislation exists on this level, the stringency of these guidelines may simply not be enough to slow down the evolution of PBM practices.
  • Researchers state that a more harmonious approach to PBM reform between each of the 50 states is necessary to ensuring increased access to health systems and better pricing for prescription drugs.

Among each material examined, documents were separated into 5 distinct categories: pricing transparency, patient access, anti-steering, audit integrity, and reporting requirements.1

Attempting to simply identify states’ legislation against PBMs, researchers noted that they plan to utilize their data to further address the variations of legislation from state to state in the future.

READ MORE: Government, Industry Leaders Address the Growing Issue of PBM Practices

States’ PBM Guidelines

In this qualitative analysis of various state-level government documents, researchers found guidelines across several states in all 5 categories of regulation.1

Researchers presented their findings on state-level PBM regulations. | image credit: fotofabrika / stock.adobe.com

Researchers presented their findings on state-level PBM regulations. | image credit: fotofabrika / stock.adobe.com

“Some of the PBM-focused state legislation was narrowly crafted to serve the financial interests of pharmacies (reimbursement requirements, maximum allowable cost list limitations, network exclusion limitations, and audit practice limitations), so there was no reason to expect that such legislation would lead to savings for patients or the health care system,” wrote Mattingly et al.2

While Mattingly et al argue that state-level PBM reform is narrowly crafted2, it’s important to note that each state is going about reform in its own way. But information on how well these legislative guidelines benefit patients’ interests is lacking.

Indeed, Pile et al found numerous documents regarding state-level PBM reform for more transparent drug pricing, better patient access to prescription drugs, less coercion to choose specific pharmacies, and more stringent auditing and reporting requirements.1

However, as researchers previously noted their desire to further analyze state-by-state variations in the future, the stringency of each guideline varies across the country.

“[The researchers’ analysis] underscores the need for ongoing research and collaboration among states to optimize the regulatory framework governing PBMs and promote transparency, affordability, and equitable access to prescription drugs in the healthcare system,” wrote the authors.1

Ultimately, the data confirms the existence of state-level PBM regulations but does not present the guidelines’ effectiveness of saving patients money at the pharmacy.

The Future Landscape of State-by-State PBM Legislation

“Policymakers may benefit from a harmonized approach that encourages consistency in key regulatory areas while allowing flexibility in addressing state-specific concerns,” continued the authors.1

With various legislative documents differing from state to state, researchers suggest that states work together to ensure the highest amount of savings for patients.

As PBM reform continues to take precedent on the Hill, authors of the study highlighted its importance for the benefit of health care in the country.

“As PBMs continue to evolve, understanding and adapting to this regulatory landscape will be vital for shaping the future of healthcare in the United States,” concluded the authors.1

While it’s understandable for state polices to vary across the country, researchers claim that if PBMs are to be regulated at the state level, each government should work in harmony, rather than individually, to block the evolution of PBMs’ price-gouging procedures.1

As the government attempts to stunt the increasing leverage of PBMs, researchers agree that more must be done, especially on the state level.

“Many of the state regulations…lacked concrete measures to ensure that there would be total savings for the system or consumers, better health outcomes, or enhanced quality of care or patient experience,” wrote Mattingly et al.2

Read more of our coverage from the 2024 APhA Annual Meeting and Exposition.

1. Pile T, Atkinson A, Ali M, et al. Prescription for reform: a comparative study of state level regulations on pharmacy benefit managers.Presented at: American Pharmacists Association Annual Meeting and Exposition; March 22-25; Orlando, FL. Poster 1286.
2. Mattingly TJ, Hyman DA, Bai G. Pharmacy Benefit Managers: History, Business Practices, Economics, and Policy. JAMA Health Forum. 2023;4(11):e233804. doi:10.1001/jamahealthforum.2023.3804
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