Credit: dreamer/Adobe Stock
Pharmacies have been so successful at fighting the pharmacy benefit managers that, at the state level, many of the best-known PBM battles are over, or nearly over.
A team at the Workers Compensation Research Institute has provided an overview of the state PBM regulation battlefield in a new report on how each state is handling many different prescription drug issues, ranging from whether a state lets pharmacists provide vaccinations to whether a state requires a pharmacist to get extra training before dispensing medical marijuana.
One table shows how each state regulates PBMs — the organizations that help self-insured employer health plans, group health insurance providers and other payers administer their prescription drug coverage.
The big picture: News about efforts to pass PBM bills in states like California, Illinois and Massachusetts may give the impression that pharmacies are still having trouble persuading lawmakers to regulate the PBMs.
The state PBM regulation chart in the new report shows that, as of Jan. 1, most states had adopted many of the highest-profile PBM rules that the pharmacists have been recommending.
All 50 states and the District of Columbia now regulate PBMs, and all but five states and the District of Columbia, require PBMs to go through a licensing, certification or registration process.
In the past, pharmacists were lobbying for bans on "gag clauses," or PBM contract terms prohibiting pharmacists from telling patients about ways to cut what they're paying for drugs.
Today, Hawaii and Ohio appear to be the only states that let PBMs include gag clauses on their pharmacy network contracts, and Hawaii lets pharmacists tell patients about generic drug options, if patients ask about that.
Any willing pharmacy rules: One disputed area is "any willing pharmacy" rules, or rules that require PBMs to take any pharmacies that are willing to accept their contract terms.
PBMs argue that any willing pharmacy provisions limit their ability to bargain for lower prices and avoid doing business with what they believe to be low-quality or inefficient pharmacies.
The pharmacies argue that restrictions on PBM network participation may hurt independent pharmacies, reduce patients' access to pharmacies and help PBMs steer patients toward pharmacies that they own or control.
At least 26 of the states in the chart now have any willing pharmacy requirements or similar requirements, but at least15 do not. For the rest, the report team described more complicated pharmacy network access rules or left a state's box for pharmacy access network rules blank.
Fiduciary standards: An emerging state-level PBM regulation topic could be fiduciary standards for PBMs, or requirements that PBMs take legal responsibility for some other party's interests first.
The chart in the new report shows that six states say PBMs owe a fiduciary duty to the insurers that hire them, to the patients that fill the prescriptions, or to both the insurers and the patients.
© Arc, All Rights Reserved. Request academic re-use from www.copyright.com. All other uses, submit a request to TMSalesOperations@arc-network.com. For more information visit Asset & Logo Licensing.