Pharmacy Benefit Managers: Updates from Capitol Hill

Recent weeks have seen a flurry of activity related to pharmacy benefit manager (PBM) oversight and regulation on Capitol Hill, with members of Congress as ideologically diverse as Senator Bernie Sanders (I-VT) and Senator Josh Hawley (R-MO) introducing different bills to increase accountability and transparency for the PBM industry. Notably, bipartisan leaders of the Senate Finance Committee, which has jurisdiction over federal health programs, introduced a framework for PBM reform that includes one of the key reforms CSRO has long advocated: delinking PBM income from drug prices. The fact that PBM income increases when a drug’s list price is higher is at the heart of many of the distorted market outcomes in the drug pricing market.

Meanwhile, the Senate Health, Education, Labor and Pensions (HELP) Committee, chaired by Senator Sanders, has announced it will consider several bills related to the pharmaceutical industry on May 2. One of the bills on the agenda is the Pharmacy Benefit Manager Reform Act, which expands transparency requirements. Although the bill includes a requirement to pass through price concessions, the PBM would pass them through to the payer. Given the high level of vertical consolidation in the industry, CSRO has always pushed for a pass-through directly to the patient, and we will continue to do so.

Finally, additional pieces of legislation were introduced by individual Members in both chambers, ranging from additional transparency requirements to outright prohibitions on price concessions. The timing was excellent: on April 20, representatives from CSRO participated in a D.C. Advocacy Day with the Alliance for Transparent and Affordable Prescriptions (ATAP). Three groups of participants visited congressional offices in the House and Senate to discuss the need for PBM reform and for providing some relief for patients in the form of reduced out-of-pocket costs and less burdensome utilization management.

Over lunch, ATAP hosted a briefing on these issues with Rep. Carter (R-GA), who is a pharmacist by background and has been a longtime advocate for PBM reform. The briefing also featured CSRO Board Member and ATAP President Dr. Robert Levin and CSRO Vice President of Advocacy & Government Affairs Dr. Madelaine Feldman, who spoke to the distortions in the pharmaceutical pricing market, the impact on patients, and the need for relief - check out some photos below!

Success in North Dakota: Specialty Pharmacy Mandates

Joining Louisiana as the second state in the nation to enact protections against specialty pharmacy mandates, North Dakota signed SB 2378 into law on April 4 with overwhelming support in both the House and Senate.

Specialty pharmacy mandates, commonly referred to as “white bagging”, is a trend among payers that seeks to replace the buy and bill system with a “white bagging” acquisition system that requires physicians to receive medication from a specialty pharmacy, which will be shipped to their office for administration. This type of model results in practices having no control over the handling, preparation, and storage conditions of a drug prior to its administration.

Under this new law, insurers will be prohibited from increasing patient cost sharing amounts or otherwise interfering with a patient's choice of provider for obtaining provider administered drugs. In addition, insurers cannot refuse to authorize, cover, or reimburse a provider for a provider administered drug because it was not acquired via white bagging. These protections are comprehensive and will help increase a patient’s access to specialty care.

Once the law has gone into effect, CSRO will provide additional details and resources – stay tuned for more information.

Business of Rheumatology Seminar June 14: Expanding Infusion Suite Services

In an effort to help support rheumatology practices in building and strengthening their businesses, CSRO launched a virtual seminar series, Business of Rheumatology.

Log in on June 14 for the second seminar in this series to learn how to expand your infusion suite services and increase market share by getting referrals from other specialties. Attendees will receive insights from a panel of experts with experience in managing this element of a practice’s business.

Business of Rheumatology:

Expanding Infusion Suite Services

Wednesday, June 14

4pm PT / 5pm MT / 6pm CT / 7pm ET

CSRO Virtual Advocacy Day: July 13

Join CSRO to meet with Federal policymakers to highlight legislation of interest to the rheumatology community! Rheumatologists around the country are invited to join us on July 13 for live conversations with health care leaders from the U.S. Senate and U.S. House of Representatives.

Your participation helps ensure that the issues impacting you and your practice are shared with members of Congress. Register now and hold the date on your calendar – specific meetings will be confirmed in June, and the schedule will be shared with attendees in the weeks leading up to the event.

Legislation Around the Country

ICYMI: Opportunity For Action in Your State

The following states have active legislation that needs your support – make your voice heard today:

California

Rebate Pass Through

Take Action: SB 873

Louisiana

Biomarker Testing Coverage

Take Action: SB 104

What's Happening in the Capitol

A bipartisan Senate companion for the HELP Copays Act was introduced on April 27 with lead sponsors Senator Marshall (R-KS) and Senator Kaine (D-VA). This legislation would prohibit the use of copay accumulators in the Affordable Care Act exchanges.

Given the harm that copay accumulators do to patients, CSRO supports this legislation and will continue to monitor and provide updates as appropriate.

What's Happening in the States

CSRO tracks legislative activity relevant to the rheumatology community and their patients. Check out the list below to see the status of CSRO priority bills from the past two weeks, and click here to view a full status report.

Be sure to check out our interactive legislative map tool for additional details.

View Status Report

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