Long-Awaited PBM Reform Included in Congress’ End-of-Year Spending Package
The American Pharmacists Association announced the inclusion of pharmacist-backed PBM reform in Congress’ end of the year spending package.
Congress plans to add key PBM reform provisions within its end-of-year spending plan for the 2025 fiscal year, according to a release from the American Pharmacists Association (APhA).1 Spurred on by pressure from pharmacists and advocacy groups around the country, the plan highlighted multiple prohibitions that will no longer allow PBMs to use their tactics on pharmacies, Medicare and Medicaid beneficiaries, and other parties who have been impacted over the years.
“Pharmacy is untied in standing up for our patients to reform the broken PBM marketplace. For years, APhA has advocated for these long overdue reforms to begin to stop PBMs’ harmful business practices that have robbed many communities of the necessary health care services they have come to rely upon,” said Michael D. Hogue, PharmD, FAPhA, FNAP, FFIP, CEO of APhA.1 “We thank our congressional champions who understand there is more work to be done. APhA and our colleagues will continue to lead the fight for meaningful PBM reforms to keep our nation’s pharmacy doors open for our patients and bring real transparency and accountability to the health care marketplace.”
Stay tuned for our ongoing PBM reform coverage. | image credit: Angelov / stock.adobe.com
The official document laying out Congress’ budgeting plan is well over a thousand pages long. However, within those pages, Congress presented various pharmacist-backed provisions for how reimbursements, pharmacy access, and more will be handled on the federal level heading into 2025.
READ MORE: NCPA Addresses Independent Pharmacists’ Hesitancy to Stock Medicare-Negotiated Drugs
One of those reforms is the establishment of benchmarks for Medicaid reimbursement at pharmacies, enabling them to receive a minimum price for dispensing drugs covered under the program. Furthermore, ensuring fair reimbursements for Medicaid drugs, the spending plan highlights that Congress will prevent PBM spread pricing—a practice that overcharges Medicaid plans and underpays pharmacies for dispensing a drug.
Section 226 of the plan details the prevention of PBMs from curating unreasonable contract terms and steering patients to pharmacies owned by the PBM.1
“The Centers for Medicare and Medicaid Services (CMS) [will be required] to define and enforce ‘reasonable and relevant’ Medicare Part D contract terms, including information about reimbursement and dispensing fees, and an approach by which ‘any willing pharmacy’ can participate, beginning January 1, 2028,” according to the news release.
These are just a few of the PBM-related reforms detailed in Congress’ 2025 plan. While the ultimate goal for PBM opposers is to see federal legislation cross the finish line, this Congressional sentiment is a positive sign for pharmacists and advocacy groups who have been calling for industry-wide change.
Aside from the Congressional budgeting plan, lawmakers have crafted several other pieces of legislation with the possibility of becoming law within the near future. Those bills include: the Better Mental Health Care, Lower-Cost Drugs, and Extenders Act of 2023 (S.3430); Modernizing and Ensuring PBM Accountability Act (S.2973); and Pharmacy Benefit Manager Transparency Act of 2023 (S.127).
And just last week, Senators Elizabeth Warren (D, Massachusetts) and Josh Hawley (R, Missouri) introduced the Patients Before Monopolies—or PBM—Act prohibiting any PBM or insurer from owning a pharmacy business.
“We’re very grateful that Congress has included NCPA’s top priorities in the continuing resolution, but now is not the time to celebrate, because the health insurance companies and their PBMs will try desperately to stop this measure from passing,” said National Community Pharmacists Association (NCPA) CEO B. Douglas Hoey.2 “Independent pharmacists across the country have done the grassroots lobbying, the letter writing, the congressional visits, and all the news interviews. Their efforts and the NCPA team’s boots-on-the-ground lobbying have all put us in scoring position. Now we’re on the goal line, and we need to punch it into the end zone.”
READ MORE: NCPA Representative Discusses Role in Influencing PBM Reform
Stay tuned for our ongoing PBM reform coverage as Congressional lawmakers begin to announce their plans for 2025 and beyond.
