Insurance Topics | Pharmacy Benefit Managers (2024)

Background

Issue:Pharmacy Benefit Managers (PBMs) are third party companies that function as intermediaries between insurance providers and pharmaceutical manufacturers. PBMs create formularies, negotiate rebates (discounts paid by a drug manufacturer to a PBM) with manufacturers, process claims, create pharmacy networks, review drug utilization, and occasionally manage mail-order specialty pharmacies.

In light ofrisinghealth carecosts, the role of PBMsarebeing reviewed due to the cost of prescription drugs and the effects on consumers.The cost of insulin andEpiPenshas been the focus ofmuch of thenews coverage,with patients being forced to ration medicine when they cannot afford copays.

Background:When insurance companies began offering prescription drugs as a health plan benefit in the 1960s, PBMs were created to help insurers contain drug spending. Originally, PBMs decided which drugs were offered in formularies and administered drug claims. In the 1970s, PBMs began to adjudicate prescription drug claims. In the 1990s, drug manufacturers began acquiring PBMs. Concerns about conflicts of interest caused federal orders for divestment from the Federal Trade Commission, sparking a trend of mergers and acquisitions within the PBM field.

Today, there are 66 PBM companies, with the three largest – Express Scripts (an independent publicly-traded company), CVS Caremark (the pharmacy service segment of CVS Health and a subsidiary of the CVS drugstore chain), and OptumRx (the pharmacy service segment of UnitedHealth Group Insurance) – controllingapproximately 89%of the market and serving about270 millionAmericans.

PBMs work in conjunction with drug manufacturers, wholesalers, pharmacies, andhealth insuranceproviders but play no direct role in the physical distribution of prescription drugs, only handling negotiations and payments within the supply chain. When a new drug is available, the manufacturer negotiates with wholesalers who then sell and distribute drugs to pharmacies. PBMs negotiate agreements with drug manufacturers on behalf of insurers and are paid rebates by drug manufacturers. Pharmacy Services Administrative Organizations (PSAOs) negotiate reimbursem*nts with PBMs on behalf of pharmacies. PBMs then pay pharmacies on behalf of health insurance providers for drugs dispensed to patients. PSAOs and PBMs are both third party companies with different functions and purposes. PSAOs represent and offer services to independent pharmacies and PBMs represent health insurers.

Pharmacy Benefit Managers earn profits primarily through administrative fees charged for their services, through spread pricing (the difference between what is paid to pharmacies and the negotiated payment from health plans), and shared savings where the PBM keeps part of the rebates or discounts negotiated with drug manufacturers. Concerns with PBM business practicesfocus ontransparency to consumers regarding rebates and reimbursem*nts. ‘Gag clauses,’ provisions in contracts between PBMs and pharmacies that prevent pharmacists from telling patients when the cash price of a drug is less than the insurance copay price, were banned in 2018 by thePatient Right to Know Drug Prices Act, S.2554and theKnow the Lowest Price Act, S.2553topromote transparency toward patients. In a 2019 study, the Government Accountability Office reported that PBMs retain less than 1 percent of rebates in a review of Medicare Part D plans, while passing the rest on to consumers. Medicare Part D rebates accounted for$18 billionof the $26.7 billion in rebates in 2016. A study conducted by the Office of Inspector General found that in Part D, rebate-adjusted unit costs increased at almost the same rate as non-rebate-adjusted costs in a 5-year period.

Actions

Status:The NAIC currently has two model laws that protect the drug benefits of consumers. The Health Carrier Prescription Drug Benefit ManagementModel Act #22provides standards for the establishment, maintenance and management of prescription drug formularies and other procedures used by health carriers that provide prescription drug benefits. The Health Benefit Plan Network Access and AdequacyModel Act #74establishes standards for the creation and maintenance ofnetworks by health carriersto ensure the adequacy, accessibility and quality of health care services offered under a managed care plan.

In order to address pharmaceutical cost drivers and the increasing concern, the NAIC created thePharmacy Benefit Manager Regulatory Issues (B) Subgroupunder the Health Insurance and Managed Care (B) Committee in November 2018. The Subgroupwastasked with creating a new NAIC Model Law to establish a licensing or registration process for pharmacy benefit managers.

A draftmodel,focusing on regulating PBMs through a standardized licensing or registration process, was adopted by the subgroup in 2020. However, ultimately the model was not adopted by the NAIC membership.Severalindividualstateshave passed legislation regarding the licensure of PBMs, spread pricing, rebate transparency, and fees.

In 2023, the Pharmacy Benefit Manager Regulatory Issues (B) Subgroup will:

1. Develop a white paper to: 1) analyze and assess the role PBM, PSAO and other supply chain entities, play in the provision of prescription drug benefits; 2) describe state regulatory approaches to PBM business practices; and 3) discuss challenges the states have encountered in implementing such regulations.
2. Developing a new NAIC model to establish a licensing or registration process for PBMs.

On April 16^th2023, awhite paper draftwas proposed by Pharmacy Benefit Manager Regulatory Issues (B) Subgroup, providing an overview of PBM industry, key stakeholders, functional issues, and state regulations.