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Your guide to PBM legislation


You can be forgiven if you're confused about all the PBM bills floating around out there. There are a lot!


We made this handy little guide to some of the leading ones, since the issue has at least some chance of making it into law this year — if members can figure out which bill, or combination, to go with.


Senate

1) HELP bill: The committee's PBM bill, set to be marked up this Thursday, could have some momentum, given its unusually broad array of cosponsors: Sens. Bernie Sanders, Bill Cassidy, Patty Murray, Roger Marshall and Mike Braun. That's a list you don’t see every day.

  • The bill would impose transparency requirements, including a report on data like the amount of rebates.

  • It also would move beyond just transparency to limiting "spread pricing," where a PBM charges a health plan more than it pays a pharmacy for a drug, and requiring 100 percent of rebates to passed through to the health plan.

  • Drug companies have generally argued for rebates to be passed through to the patient, not just the health plan, though others raise concerns about premium increases under such proposals.

The big question: Despite its bipartisanship, the bill got caught up in a messy markup last week — so can it get out of committee more smoothly this week?


2) Commerce bill: Sens. Maria Cantwell and Chuck Grassley have their own PBM bill, which has been around a bit longer, having won committee approval last year and this year.

  • This bill also would ban spread pricing. However, it would exempt PBMs if they meet requirements including passing 100 percent of rebates on to the plan sponsor and comply with transparency requirements around their costs and reimbursements.

Of note: This bill would also give more power to the FTC.

  • Some lobbyists told us they think the HELP bill has a better chance of advancing because some Republicans, including Sen. Ted Cruz, have objected to the enhanced powers for the FTC under the Commerce bill.

  • Asked if the HELP bill would eventually be merged with the Commerce bill, Cassidy told Axios that question is "above my pay grade," saying it's up to leadership.

3) Finance bill: Sens. Ron Wyden and Mike Crapo released a framework for PBM legislation last month. While the committee is farther behind HELP and Commerce and does not have bill text yet, the committee noted that it plays a key role in overseeing Medicare and Medicaid.

  • The framework points to some of the same problems, including spread pricing and a lack of transparency.

  • It also calls for "delinking PBM compensation from drug prices to align incentives for lower costs."

What we're watching: If Senate Majority Leader Chuck Schumer moves forward with a health care package on insulin and PBM measures, would the Finance effort be ready in time?

  • The Schumer package was originally set to come to the floor as soon as May, but it’s far from clear that it still will, given that Congress is caught up in the debt ceiling showdown.

House

None of the major Senate bills are direct analogues to what’s been introduced in the House, though they cover the same themes.

1) Energy and Commerce bills: The committee has discussed two PBM bills so far.

The Drug Transparency in Medicaid Act would prevent PBMs from using spread pricing tactics in Medicaid.

  • The bill would also require a survey to figure out the national average drug acquisition cost for pharmaceuticals in Medicaid.

  • Reps. Buddy Carter and Vicente Gonzalez introduced the bill with several other lawmakers from both sides of the aisle — including House Republican Conference chair Elise Stefanik.


  • Sens. Roger Marshall and Peter Welch introduced an identical bill in the Senate, and it’s been referred to Finance. We’ll watch to see if it’s rolled into bill text from the committee leaders.

The PBM Accountability Act would require the benefit managers to file reports to employers with data including the cost of drugs, total out-of-pocket spending by enrollees, formulary placement rationale and aggregate rebate information.

  • E&C health subcommittee chair Brett Guthrie and ranking member Anna Eshoo co-sponsored the bill, along with Reps. Annie Kuster and Buddy Carter.

  • The bill would also direct GAO to report on PBM practices and authorize federal agencies to enforce reporting requirements through civil monetary penalties.

2) Other bills: The Pharmacy Benefit Manager Sunshine and Accountability Act would require PBMs to publicly report data on rebate amounts, administrative feeds and other revenue from drugmakers and payers.

  • The reports would be made public by HHS at least once a year.

  • An aide to Rep. Diana Harshbarger, lead sponsor of the bill, said the office expects the bill to be included in an Energy and Commerce health subcommittee markup on May 17.

The Protecting Patients Against PBM Abuses Act focuses on actors in Medicare Part D.

  • The bill would stop spread pricing in the Medicare prescription drug program and create new reporting requirements for PBM interactions with Part D plans, effective Jan. 1, 2024.

  • It would also limit the income PBMs can receive from Part D services to only flat dollar service fees.

Don't forget: PBMs should also keep an eye on the PROTECT 340B Act, which would stop them from treating 340B entities and their contract pharmacies differently from other providers on reimbursement, network participation or inventory management systems.


What we're watching: E&C discussed the first two bills in its April 26 legislative hearing. The natural next step is a mark-up, though the committee hasn't formally announced one.

  • All the bills except the Drug Price Transparency in Medicaid Act have also been referred to the Ways and Means Committee.

  • Ways and Means plans to make announcements on PBM activity later this week, according to a spokesperson.


Axios Reporters: Maya Goldman, Peter Sullivan

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