Pharmacy, PBM Groups React to Drug Price Transparency Rule

The Department of Health and Human Services (HHS) recently released a final rule requiring health insurers to disclose drug pricing and cost-sharing information.¹

“Under this final rule, more than 200 million Americans with private-sector insurance (both individual-market and employer-based) will have access to a list of real-time price information, including cost-sharing, enabling them to know how much care will cost them before going in for treatment,” HHS said in a press release.²

“We want every American to be able to work with their doctor to decide on the healthcare that makes sense for them, and those conversations can’t take place in a shadowy system where prices are hidden,” said HHS Secretary Alex Azar, MD,. “With more than 70% of the most costly healthcare services being shoppable, Americans will have vastly more control over their care, delivering on the President’s vision of better care, lower costs, and more choice.”

Through a shopping tool available through their plan or insurance company, consumers will be able to see the negotiated rate between their physician and their plan or insurer, as well as the most accurate out-of-pocket cost estimate possible based on their health plan for procedures, drugs, and durable medical equipment, HHS said.

Ilisa Bernstein, senior vice president for pharmacy practice and government affairs for the American Pharmacists Association (APhA), praised the new rule. “We are hopeful that the HHS rule will finally bring some needed transparency to drug pricing practices of pharmacy benefit managers [PBMs]. PBMs have inappropriately enriched themselves and their affiliates, while undermining the relationship that patients have with their community pharmacists,” she told Drug Topics®.

However, APhA “will be watching closely to ensure that health plans and PBMs don’t manipulate the historical net drug prices and presentations in misleading ways to the detriment of patients and pharmacies,” Bernstein said.

Still, HHS missed an opportunity to provide relief from direct and indirect enumeration (DIR) fees, NACDS spokesperson Chris Krese told Drug Topics®.

"Any effort to reduce patients' out-of-pocket drug costs must provide relief from DIR fees and must put into place a meaningful pharmacy quality program. A transparency rule that does not address these phantom fees known as DIR fees and that does not put into place a workable pharmacy quality program stands as another missed opportunity on the part of government” Krese said.

Although the Pharmaceutical Care Management Association (PCMA) is still reviewing the final rule, “we would warn regulators to guard against giving away competitive pricing information to drug manufacturers and pharmacies,” the organization said in a statement provided to Drug Topics®.

“Mandating an increased level of disclosure for this information could result in higher prescription drug prices for consumers. The Federal Trade Commission has repeatedly stated that public disclosure of PBM-negotiated price concessions would result in tacit collusion among drug manufacturers, leading to lower discounts, or rebates, and higher drug costs for patients,” PCMA said.

References

1. Department of Health and Human Services. Final rule: transparency in coverage. United States Federal Register; October 29, 2020. https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/CMS-Transparency-in-Coverage-9915F.pdf

2. Trump Administration finalizes rule requiring health insurers to disclose price and cost-sharing information. News release. HHS; October 29, 2020. Accessed November 18, 2020. https://www.hhs.gov/about/news/2020/10/29/trump-administration-finalizes-rule-requiring-health-insurers-disclose-price-and-cost-sharing.html