Senate Advances New Bill Seeking PBM Reform

The Senate Finance Committee unanimously voted to advance the Better Mental Health Care, Lower-Cost Drugs and Extenders Act, a comprehensive bill seeking increased transparency and comprehensive PBM reform. The bill also would create a list of discounted drugs with high rebates available in Medicare Part D and address various other healthcare issues. Among the provisions in the bill are the following:

  • The Medicare physician fee schedule services statutory increase of 1.25% would increase to 2.5% in 2024, thereby slightly increasing the physician payment rate.
  • Eligibility for bonuses under the Health Professional Shortage Area program would extend to non-physician healthcare professionals providing certain mental health and substance use disorder services.
  • The HHS Secretary would be required to provide information on licensing requirements for furnishing telehealth services under Medicare and Medicaid, including clinicians providing telehealth services to patients in neighboring states.
  • Network-based Medicare Advantage plans would be required to verify provider directory information at least every 90 days.
  • Beginning in 2028, Medicare Part D plan sponsors offering preferred pharmacy networks would be required to contract with the following:
    • At least 80% of essential retail pharmacies in the plan’s service area that are independent community pharmacies; and
    • At least 50% of essential retail pharmacies in the plan’s service area that are not independent community pharmacies.
  • Part D plans would have to base enrollee drug copays on the drug’s net price, including projected manufacturer rebates, rather than their Part D negotiated price.

PBMs, through the Pharmaceutical Care Management Association, are already pushing back on the proposed legislation. They argue that the legislation would add even more uncertainty to Medicare Part D plans, emphasizing that the Inflation Reduction Act has already created changes to Part D, the overall impact of which remains unknown.

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