It's Not Just Congress. There's Plenty of State-Level Action on PBMs, Drug Costs and Prices | AMCP 2024

Although the spotlight has shifted to Congress and legislation it might pass concerning pharmacy benefit managers (PBMs), state legislatures and healthcare regulators are also enacting new laws and issuing new rules affecting the industry.

Adam Colborn, director, government affairs, of Academy of Managed Care Pharmacy (AMCP) discussed state-level developments today at presentation at AMCP’s annual meeting in New Orleans.

In an interview with Managed Healthcare Executive prior to the meeting, Colborn discussed four trends in state-level legislation and regulation: transparency, PBM spread pricing and rebate pass throughs, copay limits and accumulators and efforts by states to control their own drug costs.

Colborn said AMCP is seeing a great deal of legislation introduced creating new PBM and pharmaceutical industry reporting requirements. In some cases, those requirements are tied to existing licensing requirements. In others, entirely new boards that only focus on PBMs and drug pricing have been created. He noted that the transparency and reporting requirements are typically to the state and not to consumers or patients.

Colborn noted that there are proposals at both federal and state levels to prohibit spread pricing, the name for drug pricing arrangements in which there is a difference between what the PBM charges the pharmacy and what it collects from the payer. Colborn said there also numerous proposals that would require 100% of rebate paid by manufacturers to be passed through to the plan sponsor or to the individual patient.

In this interview with MHE, Colborn also mentioned that there are numerous proposals to cap copayments and for therapies other than just insulin. There are also state-level prohibitions on PBM copay accumulators, the payment arrangements that remove the value of copay assistance programs from calculations of a patient’s deductible.

To control their own drug costs, some states have created prescription drug affordability boards, said Colborn ,noting that Colorado’s was the first to find a drug — Enbrel (etanercept) unaffordable — and therefore subject to a price cap. Amgen, the marker of Enbrel, has filed a lawsuit challenging the cap.

Like other payers, states are wrestling with costs associated with the growing number of prescriptions for the GLP-1 drugs for weight loss, Colborn said.