PBM Reform

Policymakers frequently target pharmacy benefit managers (PBMs) in a well-meaning attempt to contain rising drug prices, but some proposed changes could have the opposite effect. These include prohibitions and restrictions on many of the utilization management tools that PBMs use to ensure quality and manage costs, as well as the contractual payment relationships between PBMs and the plan sponsor. We are concerned that the impact of these changes could ultimately raise overall plan costs because it limits the ability to drive utilization to more cost-effective products and services.

These changes could result in higher plan premiums and member cost-sharing. AMCP encourages PBM reform efforts to focus on common-sense requirements for transparency reporting by PBMs. AMCP believes that these requirements can demonstrate the benefits of PBM efforts to control costs through a variety of utilization management strategies as well as by negotiating drug rebates and other price concessions from drug manufacturers.

The current discourse about PBMs feels more like a blame game than conversation meant to produce a solution. It’s time for a more nuanced discussion about PBM reform—one that lowers the temperature and puts patients first.

• As of January 2023, approximately 275 million Americans received pharmacy benefits administered by PBMs. 
• Common provisions of PBM-focused legislation include increased prohibitions against spread pricing, counting manufacturer assistance program payments towards deductibles, rebate pass-through requirements, and restrictions on reimbursement rates for affiliated pharmacies. 
• While many of these provisions are well-intentioned, AMCP believes a competitive marketplace should determine compensation for services, rather than artificially regulated constructs. 

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