What States are Doing to Regulate Pharmacy Benefit Managers

State laws that regulate pharmacy benefit managers (PBMs) have created a patchwork of rules, according to a poster presented at the 2024 American Pharmacists Association Annual Meeting and Exposition.

Thomas L. Pile, Pharm.D.

Researchers — led by Thomas L. Pile, Pharm.D., clinical assistant professor, director of Co-Curricular, at Marshall University in West Virginia — examined legislative documents, administrative codes, and regulatory guidelines to gain insight into how states are regulating PBMs. Researchers separated these into five distinct categories: pricing transparency, patient access, anti-steering, audit integrity, and reporting requirements.1

Pile and his colleagues found numerous documents regarding state-level PBM reform for more transparent drug pricing, better patient access to prescription drugs, less coercion to choose specific pharmacies, and more stringent auditing and reporting requirements.1

“[The researchers’ analysis] underscores the need for ongoing research and collaboration among states to optimize the regulatory framework governing PBMs and promote transparency, affordability, and equitable access to prescription drugs in the healthcare system,” wrote the authors.1

Ultimately, the data confirms the existence of state-level PBM regulations but does not present the guidelines’ effectiveness of saving patients money at the pharmacy.

“Some of the PBM-focused state legislation was narrowly crafted to serve the financial interests of pharmacies (reimbursement requirements, maximum allowable cost list limitations, network exclusion limitations, and audit practice limitations), so there was no reason to expect that such legislation would lead to savings for patients or the health care system,” wrote researchers in a paper published in JAMA Health Forum in November 2023. 2

While Joseph Mattingly II, in the department of Pharmacotherapy at the University of Utah College of Pharmacy, and his colleagues argue in the JAMA Health Forum article that state-level PBM reform is narrowly crafted, it’s important to note that each state is going about reform in its own way. But information on how well these legislative guidelines benefit patients’ interests is lacking, they said.

With various legislative documents differing from state to state, researchers from the poster presented at American Pharmacists Association meeting suggest that states work together to ensure the highest amount of savings for patients.

“As PBMs continue to evolve, understanding and adapting to this regulatory landscape will be vital for shaping the future of healthcare in the United States,” concluded Pile and his colleagues.1

“Many of the state regulations…lacked concrete measures to ensure that there would be total savings for the system or consumers, better health outcomes, or enhanced quality of care or patient experience,” wrote Mattingly and his colleagues in the JAMA Health Forum paper.2

References

1. Pile T, Atkinson A, Ali M, et al. Prescription for reform: a comparative study of state level regulations on pharmacy benefit managers.Presented at: American Pharmacists Association Annual Meeting and Exposition; March 22-25; Orlando, FL. Poster 1286.

2. Mattingly TJ, Hyman DA, Bai G. Pharmacy Benefit Managers: History, Business Practices, Economics, and Policy. JAMA Health Forum. 2023;4(11):e233804. doi:10.1001/jamahealthforum.2023.3804

This story first appeared on Drug Topics and has been edited.