Bipartisan legislators revive PBM reform debate on the Hill

Fierce Healthcare

Reporter: Paige Minemyer

While major pharmacy benefit management reform was stripped out of the Big Beautiful Bill, a bipartisan group of representatives has introduced legislation that takes aim at the industry.

The PBM Reform Act, led by Republican Rep. Buddy Carter of Georgia, seeks to ban spread-pricing models in Medicaid and instead move to a more "transparent" system that the legislators say will more fairly reimburse pharmacies for the services they provide.

In addition, the bill would delink PBM compensation from medication costs within Part D, and establish semi-annual reporting that provides further detail on spending, rebates and formulary decisions for plan sponsors and members.

These policy changes have been thrown around multiple times in a bid to overhaul the PBM industry, and while efforts have traditionally enjoyed bipartisan support, reform measures have repeatedly sputtered in Congress.

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Carter's bill would also mandate that the Centers for Medicare & Medicaid Services create and enforce contract terms in Part D that are "reasonable and relevant" and ensure there is more oversight on potential violations, according to an announcement.

In the press release, Carter also slammed vertical consolidation in the PBM industry and calls to "bust up the PBM monopoly," though the bill does not go so far as to break up these companies. 

The PBM market is largely controlled by three firms: CVS Caremark, Express Scripts and Optum Rx. Each of these companies is vertically integrated with a large national insurer: Aetna, Cigna and UnitedHealthcare, respectively.

"As a pharmacist, I’ve seen how PBMs abuse patients firsthand, and believe that the cure to this infectious disease is transparency, competition and accountability, which is exactly what our bipartisan package provides,” Carter said... Continue Reading