In airy of ongoing provider shortages, some pharmacists are taking on additional responsibilities to fill the gap. (Photo: Whitney Downard/Pennsylvania Capital-Star)
Pennsylvania’s latest budget includes a number of policy provisions that lawmakers in the negotiations agreed to.
One is aimed at helping pharmacies that claim a pharmacy benefits manager arbitrarily prevented them from accepting certain Medicaid plans.
The fresh rule will require pharmacy benefit managers, or PBMs, to allow pharmacies with which they previously terminated contracts to reapply to their networks after 12 months, provided they meet state and federal regulatory requirements.
While this solution does not address many of the concerns pharmacists have raised about PBMs, including the low reimbursement rates for the drugs they dispense, it does address a problem faced by several struggling Pennsylvania pharmacies.
“This is very good news for probably dozens of pharmacies across the state that are experiencing network issues related to PBM devices that prevent them from accessing the MCO network,” said Rob Frankil, executive director of the Philadelphia Association of Retail Pharmacists.
Pharmaceutical benefit managers (PBMs) are intermediaries in the pharmaceutical supply chain. They are hired by insurance companies to handle the prescription drug aspects of their health care plans.
In this role, PBMs reimburse pharmacies for patients’ purchases of drugs covered by their insurance. If a pharmacy wants to accept a patient’s insurance, it must sign a contract with the PBM that represents it, agree to the reimbursement rates it sets, and follow other rules it sets.
Pharmacists have long blamed PBMs for falling revenues and rising drug costs. The three largest PBMs—CVS Caremark, Express Scripts, and Optum—are part of huge health care conglomerates and together process approximately 80% of all prescription drug claims in the United States.
This means that pharmacists must remain in good standing with them if they want to accept a enormous number of their patients’ insurance plans.
But many pharmacists warned that PBMs could be capricious in their contractskicking pharmacies out of their networks for reasons that may seem arbitrary.
A spokesman for the Pharmaceutical Care Management Association, an industry group representing the largest PBMs, declined to comment on the matter.
Over the past few years, attempts to regulate PBMs have brought Democrats and Republicans closer together.
Since 2020, more than 1,000 pharmacies have closed across the state. Pharmacists and their representative industry groups they are putting pressure on the legislator enact legislation to regulate PBMs.
Republican Senator Dave Langerholc (R-Clearfield) and Democrat Frank Burns (D-Cambria) spoke about the provision in the budget.
