ALEXANDRIA, Va. A congressional bill that aims to reduce healthcare costs by requiring greater transparency of pharmacy benefit managers has garnered praise from an industry group representing the nation's independent pharmacists.
The National Community Pharmacists Association has endorsed H.R. 5234 -- the PBM Audit Reform and Transparency Act of 2010 -- a bill introduced by Rep. Anthony Weiner, D-N.Y. that seeks to limit ownership conflicts of interest, discourage abusive pharmacy auditing practices and require greater PBM disclosure with patients and plan sponsors.
H.R. 5234 offers a regulatory framework at the federal level with provisions requiring PBMs to:
- Disclose to plan sponsors in an annual report the number/total cost of prescriptions under the contract filled at mail and retail; aggregate average payments under the contract per prescription made to mail and retail and average amount per prescription the PBM received; overall percentage of generics dispensed at mail and retail; and percentage and number of cases patients where switched to a more costly drug
- Identify sources for maximum-allowable cost pricing and reimbursement benchmarks and update weekly; follow prompt pay provisions (consistent with the Medicare Part D prescription benefit); and be non-discriminatory regarding pharmacy network participation
- Cease ownership conflicts of interest by preventing PBMs from mandating that patients use a specific pharmacy (retail, mail, specialty) if the PBM has an ownership interest in that pharmacy (or vice versa); and prohibit the offering of incentives to encourage patients to use only the PBM-owned pharmacy
- Give pharmacies a 15-day prior notice of audits; offer a written appeals process; limit the audit period to one year; and disclose audit recoupment to the plan sponsor.Protect patients by placing restrictions on the sale/utilization of claims data and other patient information.
“This legislation would begin to rein in many of the dubious and opaque PBM practices that pad their burgeoning profits at the expense of patients, plan sponsors and local pharmacists,” said Joseph Harmison, NCPA president and pharmacy owner. “If this bill is enacted, PBMs would find it much harder to pad profits through hidden costs, to steer patients away from their pharmacy of choice and towards PBM mail order pharmacies and to punitively audit pharmacies. Ultimately, this proposal’s about fixing the complex, broken system that PBMs have put in place to make billions of dollars while leaving patients and health plan sponsors paying the bill and scratching their heads.”
The Pharmaceutical Care Management Association, a group that represents PBMs, lambasted the legislation, saying it would increase prescription drug costs and limit patient access.
“Unfortunately, the independent drugstore lobby continues to push an agenda that increases prescription drug costs for consumers and payers and limits efforts to root out fraud, waste and abuse,” a PCMA statement read. “Given the increased focus on controlling health care costs, we can’t afford to let anyone, including the independent pharmacy lobby, thwart congressional efforts to fight pharmacy fraud.”