“PBM” Reform and Defending Patient Access

79%

Pharmacists Most Credible on Prescription-Drug Savings

say pharmacists are “very credible” or “somewhat credible” sources when it comes to information about how to save money on prescription drugs – ranking them highest among those tested (others tested include doctors, hospitals, health insurance companies, pharmaceutical companies). 

Pharmacists Most Credible on Prescription-Drug Savings

79%

say pharmacists are “very credible” or “somewhat credible” sources when it comes to information about how to save money on prescription drugs – ranking them highest among those tested (others tested include doctors, hospitals, health insurance companies, pharmaceutical companies). 

Morning Consult conducted this poll between December 7-December 12, 2022, among a sample of 20,010 Adults. The interviews were conducted online and the data were weighted to approximate a target sample of Adults based on gender, age, race, educational attainment, and region. Results from the full survey have a margin of error of plus or minus 1 percentage points. NACDS commissioned the poll.

PBM Reform Demands Action by All-Branches,
All-Levels of Government

The complexities of the issues make it necessary for the federal and state governments to do their part to bring about comprehensive PBM reform. Only if the federal and state governments do their respective parts will reform prevent “pharmaceutical benefit manipulation” across all markets – Medicare, Medicaid, and commercial.

For All In Government

Stop Manipulation of Drug Prices, Medication Access, & Pharmacy Freedom

“PBM”s make $315 billion annually – rising to $740 billion by 2029. See how they do it at the expense of patients, pharmacies, and others. And how to fix it.

Stop PBM Manipulation
Principles of PBM Reform

PBM reform is vital for patients and pharmacies.

These are essential principles for comprehensive PBM reform – to help stop PBMs’ manipulation and to stand up for patients’ pharmacy access and for pharmacies’ survival:

Stop explosive retroactive fees.

Stop PBMs and payers from using “DIR fees” and other tactics to grab back the payments made and owed to pharmacies – often many months after the fact and often resulting in below-cost pharmacy reimbursement.

Adopt a rate floor that prevents PBMs and payers from reimbursing pharmacies below the true cost of acquiring and dispensing prescription drugs.

Standardize performance measures to help improve patient outcomes and reduce costs – rather than allowing PBMs and payers to play “gotcha” with pharmacies using arbitrary measures and exorbitant fees.

Prevent PBMs and payers from defining “specialty drugs” in ways that steer patients with rare or complex diseases away from their preferred pharmacy and toward another pharmacy – including those owned by the PBMs and payers.

Prohibit PBMs and payers from forcing patients to use mail-order pharmacies – including those owned by the PBMs and payers – and prohibit them from imposing penalties on patients for choosing a convenient and trusted pharmacy in their neighborhood.

Require PBMs and payers to include in their networks all pharmacies willing to accept terms and conditions established by the PBM.

Bring efficiency, transparency, and standardization to the processes by which PBMs audit pharmacies without sacrificing continuity of care.

Prioritize the implementation, enforcement, and oversight of PBM reform laws – to maximize results for patients and fairness for pharmacies and other stakeholders, and to ensure laws are not undermined by inaction of PBMs or of government.

For the U.S. Congress

Real PBM Reform Must Protect Americans on Medicare and Medicaid, and Their Pharmacies

March 2024 Press Conference

“Get It Done” Ad

“Real Reform” Ad

The gold standard for PBM reform in Medicaid is the bipartisan Drug Pricing Transparency in Medicaid Act, S. 1038/H.R. 1613. The gold standard for PBM reform in Medicare is the bipartisan Protect Patient Access to Pharmacies Act, S. 2052. Medicare legislation that also would help to hold PBMs accountable is the Neighborhood Options for Patients Buying Medicines Act, S. 2436/H.R. 5400. To varying degrees, aspects of these bills are included in larger pieces of legisltaion making their way through Congress. Also of importance is the investigation underway by the U.S. House of Representatives Committee on Oversight and Accountability.

For the States

Bipartisan Focus is Producing Results Across the Nation

States are recognizing the need to enact PBM reform – and to press forward with implementation, enforcement, and oversight despite PBMs’ efforts to roll back reforms. States enacted 101 PBM reform bills in 2021 and 2022. In 2023, 31 bills have been enacted across 27 states, which have led to 55 policy changes consistent with NACDS’ Principles of PBM Reform. One or more aspects of the NACDS Principles now have been adopted in every state – though much, much more work is needed in the states. Further, this does not in any way mitigate the need for federal action on the issues that it must address.

State Spotlight:

NACDS Urges Massachusetts to Proceed with Much-Needed PBM Reform Legislation