Pharmacy benefit managers (PBMs) often administer prescription drug benefit plans for commercial health insurance plans and self-insured employer plans. They are the intermediaries between insurers and prescription drug companies. PBMs have been criticized in recent years for failing to pass along savings derived from negotiated drug manufacturer rebates and discounts from retail pharmacies to consumers. Georgia Watch supports SB 103 and HB 276 relating to the regulation of pharmacy benefit managers.
- Mandatory mail order (charging higher co-pays when consumers do not use mail order pharmacies), and not letting patients use the pharmacies of their choice.
- Restricting pharmacies from offering delivery services to their patients.
- Steering or referring patients to out-of-state PBM-owned pharmacies and applying other provisions in Georgia’s self-referral statute.
- Charging patients more than pharmacies are reimbursed for the drug. We understand that, for example, a PBM may force a pharmacy to charge a patient $50 when the cash price of the drug is $20. The additional $30 goes to the PBM. This is sometimes called a “clawback.”
- Restricting pharmacies from providing patients information regarding less costly prescription drugs or interfering with a pharmacist’s ability to provide pharmacy care. Patients should have the right to know when there is a cheaper generic available. This prohibits PBMs from forcing patients to use more expensive drugs for which the PBM may receive a rebate from the drug manufacturer.
- Restricting pharmacists from advocating to PBMs on behalf of patients.
This bill also proposes to give the Commissioner of Insurance the authority to promulgate rules and regulations in connection with the PBM code. Currently, the Commissioner does not have that authority.
We are happy to report that this legislation passed during the 2016 Legislative Session.