Gag clauses prevent pharmacists from disclosing that a drug is cheaper to buy at its cash price, rather than with insurance. The Arkansas bill, like recent legislation in other states, will eliminate the gag clause. Also, three bills that would eliminate gag clauses at the federal level are currently circulating in Congress, says ACR Director of Regulatory Affairs Kayla Amodeo, PhD.
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“Patients are affected by PBMs in multiple ways,” says Dr. Worthing. “The prescription that is best for them, which they and their rheumatologist have agreed upon, may not be covered because the drug didn’t garner enough rebate money for PBMs to place it on formulary. Or the co-payment a patient pays may be higher because it is based on the list price instead of the discounted price. When paying out of pocket is cheaper than obtaining a drug through insurance, patients often remain unaware, because pharmacists can’t inform them.”
Pharmacists Push Back
In Arkansas, pharmacists argued that these practices have also resulted in hardships for smaller pharmacies, particularly in rural parts of the state where patients may already have fewer options.
“It was evident from discussions with the governor that part of his motivation in signing the bill was to better understand the role of PBMs in the healthcare market and their impact on local pharmacies,” says Mr. Cantrell.
The ACR would like to see other states or the federal government pass legislation to address PBM practices that affect patient access to care. The ACR is also working at the federal level to educate members of Congress on the broad implications of PBM practices, says Dr. Amodeo.
In February, the ACR visited Capitol Hill with ATAP to meet with legislators to assure them that regulation of PBM practices would not violate the Centers for Medicare & Medicaid Services’ non-interference clause, which prohibits the Secretary of Health and Human Services from establishing a single formulary and from interfering in the negotiations between plans and manufacturers. Even with PBM regulation, insurers could still engage with manufacturers in establishing prices.
“People across the country are starting to understand the complex problems of consolidation, opacity and perverse incentives in the PBM system,” says Dr. Worthing. “We’re optimistic that more and more bills will become law at all levels and that our patients will benefit from lower prices and easier access to the high-quality treatments they deserve.”
Kelly April Tyrrell writes about health, science and health policy. She lives in Madison, Wis.