Skip to content

Policymakers Trying to Refocus PBMs on Patients

Florida is center stage in the national movement to reform the powerful pharmacy benefit manager industry and return the focus from profits to patients. 

Pharmacy benefit managers are often called “middlemen” for their role in negotiating drug prices with manufacturers on behalf of health insurers. They also administer pharmacy benefit programs, operating there as the middleman between patients and their insurance company – often to the detriment of patients who face PBM-driven barriers.  

Florida’s Reform Legislation 

Florida lawmakers are moving legislation that would add more industry oversight in response to a bevy of complaints. Chief among the concerns are: 

  • the manipulation of drug prices for the PBM’s benefit while simultaneously restricting patients’ coverage of needed medications 
  • the acceptance of rebates from drug manufacturers without passing savings on to patients in the form of lower prices and co-pays 
  • the vertical integration that’s occurring as more PBM’s are owning and operating their own mail order and specialty pharmacies. 

Florida’s bipartisan effort, which has the support of Governor Ron DeSantis, aims to increase transparency by making more records publicly available.  

It would also regulate pharmacy benefit managers’ contracts with insurance companies and pharmacies, prohibiting practices like: 

  • clawbacks, when the PBM takes back overpayments caused when a patient’s copayment exceeds the total cost of the drug, and  
  • spread pricing, when a PBM charges a health plan more to process a prescription than the amount it reimburses to the pharmacy and pockets the difference. 

“The ultimate goal of this bill is to help patients in Florida with pharmacy benefit coverage receive their medications in a more accessible manner, and at a more affordable cost,” Senator Jason Brodeur, one of the legislation’s sponsors, explained. 

Advocacy in Action 

Advocates have been involved in getting more patient protections added to the bill, which initially focused primarily on the relationships between pharmacy benefit managers and independent pharmacies.  

At the urging of patient advocates, lawmakers added language that prevents harmful formulary changes. Now, the bill includes a 60-day notice requirement that forces PBMs to alert patients prior to making a formulary change that takes away medications or makes them more expensive. 

Familiar Complaints 

In addition to the legislation in Florida, there are reform bills moving in statehouses across the country and pharmacy benefit managers remain under scrutiny in the country’s capital. The Federal Trade Commission has an ongoing investigation and senators have reintroduced a transparency act that “seeks to outlaw several practices that pharmacies charge are unfair.”  

There’s broad agreement that pharmacy benefit managers are ripe for reform, but as policymakers across the country look to adjust, they should do so with patients’ best interest top of mind. 

Related Articles