Summer is fast approaching, and although temperatures are warming outside, the temperatures in most state capitols are cooling as sessions are ending and legislators are heading home for the balance of the year. That also means it is a good time to step back and take stock of where things stand. As the season winds down, it is important to remember that this is the first year of a two-year session for most states. That means that even if a bill did not make it over the finish line this year, there is still hope for success next year. With that in mind, it is time to look at some of our key wins and losses from this year so far.
Key PBM Reforms
From Capitol Hill to your local state house, pharmacy benefit managers (PBMs) continue to be a favorite punching bag of legislators. States continue to look at ways to regulate some of what is seen as bad behavior in the PBM space.
This year there was a spate of bills seeking to require rebates to be “passed through.” This simply means that PBMs would be required by law to pass through a certain percentage of a rebate to the patient and/or plan sponsor. Most bills being considered this session require anywhere from a 70–100% pass through. Unfortunately, the legislation did not survive in several states, such as Georgia and Virginia.
However, there were a few significant wins as well. Arkansas approved legislation (HB 1481) that requires a patient’s cost-sharing responsibility at the point of sale be reduced by an amount equal to 100% of the rebates that are received or expected to be received by a PBM. Indiana also passed rebate pass-through legislation (SB 8). This bill requires a patient’s cost-sharing responsibility to be reduced by at least 85% of the amount of the expected rebate at the point of sale. It also requires 100% of the rebates to pass through to the plan sponsor.
Although these are potentially significant wins for patients, we must monitor the implementation process. There are some potential unintended consequences to these reforms, such as rebate amounts lower than was anticipated at the time of sale or the discontinuation of a rebate after a drug has been purchased by a patient. This could lead PBMs to claw back funds from patients with surprise bills for pharmaceuticals they already purchased and used. Existing claw-back bans only apply to pharmacies, so patients are vulnerable to a new claw-back scheme.
