Last week I did an explainer on what pharmacy benefit managers (PBMs) are and where the pain points were and why there was a focus on PBM reform.
There is a lot of buzz around PBM bills on Capitol Hill last year with lots of bills in motion but, for now, I’d thought I’d hone in on two in particular and give a little compare and contrast. If you can’t get enough, there is also Senate HELP’s bill (S. 1339) and Senate Commerce’s bill (S. 127) which may have some legs.
| Senate S. 3430 Better Mental Health Care, Lower-Cost Drugs, and Extenders Act (Better Health) & S.2973 Modernizing and Ensuring PBM Accountability Act (MEPA) | House of Representatives H.R. 5678 Lower Costs, More Transparency Act | |
| Status | Waiting in the Senate | Passed the House in December 2023 |
| Market Impacted | Medicare Part D Medicaid | Group Health plans (governed by IRS, ERISA) Medicaid, Medicare Part D |
| Delinking admin fee from drug cost | Yes, for Part D. Other price concessions, rebates and discounts must be passed to patient. | No |
| Spread pricing | Not permitted in Medicaid | Not permitted in Medicaid |
| Rebate pass-through | Must be 100% passed through for Medicaid | No |
| Patient out-of-pocket | Ties patient coinsurance to net price | No |
Both these bills include a lot on PBM reporting requirements including a listing of drugs covered and dispensed and the gross and net cost, cost-sharing, and rebate information.
But they are very different approaches that can’t really be thrown together. I appreciate the Senate Finance bill’s inclusion of delinking and having price concessions passed on to the beneficiary, but it is also possible that giving 100% back to beneficiaries might be a set too far (for now?). I like the idea of stopping spread pricing but would love to see it beyond just Medicaid.
HR 5678 is so focused on reporting that I am wondering what you DO with the information; it feels like a heavy lift to kick the can to a future legislative change once you have the information.
With no mention of PBM reform in the State of the Union, I wonder if that signals it is over. Or maybe it just doesn’t make a great talking point. Yet with so much time and effort spent on PBM reform, I hope that something comes together this year.