Bill to reign in PBM practices, protect community pharmacies, sponsor says

A new bill, H.R. 4215, The Medicare Pharmacy Transparency and Fair Audit Act, recently introduced by Rep. Cathy McMorris-Rodgers (R-WA), would help address 2 big challenges faced by community pharmacists-transparency in setting pharmacy reimbursement and abusive pharmacy audit practices, according to its sponsor.

“H.R. 4215 is focused on setting up parameters for pharmacy benefit manager (PBM) audits, and it requires transparency for PBM pricing of drugs. It gives us the opportunity to really educate and bring this legislation forward to committee and highlight PBM practices,” explained Rep. McMorris-Rodgers, during a media call with the National Community Pharmacists Association (NCPA) leadership at its 44th annual NCPA Legislative Conference in Washington, D.C. Rep. McMorris-Rodgers is co-chair of the House Community Pharmacy Caucus with Rep. Mike Ross (D-AR-4th).

This legislation, introduced in March 2012, would require Medicare Part D plan sponsors to inform pharmacies about the methodology and resources used for setting the maximum allowable costs (MAC) reimbursement limits. These plans would need to provide updated pricing information weekly to more accurately reflect changes in drug costs, according to an NCPA news release.

H.R. 4215 also would halt “abusive” pharmacy audits by not subjecting pharmacies “to record-keeping requirements that exceed federal or state law. In addition, approved prescription claims could not be overturned due to clerical errors unless the auditor could demonstrate both the pharmacy’s intent to commit fraud and the error increased costs to the plan,” the NCPA statement said.

H.R. 4215, is a narrower version of H.R. 1971, The Pharmacy Competition and Consumer Choice Act, also introduced by Rep. McMorris-Rodgers last year. H.R. 1971, which only has 24 sponsors, had difficulty gaining traction because the Congressional Budget Office has not yet released a score to demonstrate the cost associated with the earlier bill. H.R. 4215 only applies to Medicare, but the larger bill (H.R. 1971) applied to both commercial plans and Medicare, noted John M. Coster, PhD, RPh, senior vice president of government affairs and director of the Center for Community Pharmacy Advocacy, NCPA.

“H.R. 4215 is considered budget-neutral and members of Congress would be more willing to sign onto it,” explained Rep. McMorris-Rodgers. “At least it would start the discussion on the PBM issue.” She is hopeful that there will be a hearing on the bill before the presidential election in the fall, she said.