Federal, state legislative prospects discussed: Asembia 2022 Specialty Pharmacy Summit

New bills at the state and federal levels could change reimbursement for medications, as well as allow for the real-time exchange of patient data that maximizes the way the pharmacists work, according to Tracy Russell, CoverMyMeds’ senior director of state and government affairs.

“Helping patients get the medication that they can afford — even if it might not be the first choice of the provider — helps patients be adherent, which is the key goal of these efforts,” she said in an interview prior to her presentation today at the 2022 Asemiba Specialty Pharmacy Summit in Las Vegas. Russell spoke at a session about federal and state legislation affecting specialty pharmacy along with Joel White, founder and president of Horizon Government Affairs, a healthcare consultancy.

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Federal legislative proposals aim to lower drug costs, provide access to care, and access to data, while several states are focusing on banning the practice of steering patients to specialty pharmacies.

The stalled Build Back Better legislation includes several provisions that might have affected Medicare and prescription drugs offered covered by the program, Russell noted. The provisions would have allowed the federal government to negotiate prices for high-cost drugs under Medicare Part B and Part D, cap out-of-pocket spending for Medicare Part D patients, assess inflation penalties, limit cost-sharing for insulin and eliminate cost sharing for adult vaccines.

The Congressional Budget Office estimates that the ability to negotiate prices alone would save Medicare $78.8 billion over 10 years.

“If advanced as it is today, it would redesign Medicare Part D,” Russell said. “The Medicare Part D proposal would define the negotiated price at the lowest amount that a pharmacy could receive for a drug under the contract with its plan.

But Build Back Better legislation didn’t get through the Senate. Which provisions might get passed prior to the mid-terms this fall is unclear, but they are almost certainly going to narrower. Capping out-of-pocket costs of insulin is one possibility.

Legislation to expand access to care, Russell said, includes the Equitable Community Access to Pharmacist Services Act, which was introduced in the House of Representatives in March 2022. The legislation would authorize pharmacists to provide care and receive reimbursement for pandemic-related services for Medicare Part D beneficiaries. “This would add pharmacists as a Medicare provider for some of the services where they'd be reimbursed at 85% of the fee schedule,” Russell said.

The third area is access to data. “Data is a big topic all across the board with questions about whose data is it and who has access to that data,” Russell said.

The Centers for Medicaid and Medicare Services in January 2022 issued a final rule referred to as “a real time benefit tool” for Part D plans. This rule, which takes effect in January 2023, allows enrollees to know in advance and compare their out-of-pocket payments for different prescription drugs.

“This would allow enrollees to know patient-specific information — which is key — about their benefits and costs at the point of prescribing instead of at the pharmacy. When this is implemented, it is going to pave the way for patients to be able to navigate their affordability and freedom to work with their doctor on the affordability. This helps the doctors also, because when writing a prescription they wouldn’t know if the patient's going to pick it up or not, if they can afford it when they get to the pharmacy.”

At the state level, there are attempts to address what is called “white bagging” in about 11 states, Russell said. White bagging is when medications, typically specialty drugs, are administered through a specialty pharmacy instead of at the doctor’s office or hospital. This is sometimes required by plans to help manage hospital pharmacy costs.

But this can create a more complicated situation for the patient, Russell said. “The pharmacy charges the patient for their medication prior to administration, and usually that’s through a copay. The providers then bill for admin fees and take on the liability even though they don’t have direct control of the product. Some states are trying to prohibit the pharmacy benefit managers from steering patients to a specific specialty pharmacy.”

Louisiana, for example, is one state that has already enacted such legislation. On June 1, 2021, the governor signed a bill that requires insurance companies to reimburse for physician-administered drugs. Similar bills have been introduced in Kentucky, Nebraska and West Virginia.