ALEXANDRIA, Va.  — The National Community Pharmacists Association has urged the West Virginia Offices of the Insurance Commissioner to watch out for pharmacy benefit manager “games” when developing rules to implement reform legislation approved by Republican Gov. Jim Justice (R). Among other things, HB 2263 will implement reporting requirements to ensure transparency; prevent PBMs from charging higher copayments when patients go to a pharmacy of their choice; and ensure minimum reimbursement rates in line with rates a PBM pays to mail order pharmacies and other pharmacies owned by or affiliated with a PBM.

National Community Pharmacists Association Logo. (PRNewsFoto/National Community Pharmacists Association)

Studies in states across the country have revealed that PBMs are overcharging for their services, reimbursing pharmacies low for medications dispensed, billing the state Medicaid program high for the cost of those medications, and retaining the difference, called “spread,” according to NCPA. Additionally there have been issues with PBMs reimbursing pharmacies below acquisition cost, steering patients to pharmacies owned by or affiliated with PBMs, and other anticompetitive behaviors.

West Virginia started directly managing its Medicaid managed care prescription drug benefit in July 2017. The state saved $54 million in the first year after it took over management of the benefit.

NCPA is urging the state to specify that pharmacy reimbursement should be inclusive of all fees, clawbacks, etc. that a PBM charges a pharmacy and that net reimbursement cannot be lower than the acquisition cost and required dispensing fee. The association is also pushing for language giving more flexibility to enforce the law’s provisions against ERISA plans to the full extent allowed by federal law and federal decisions such as Rutledge v. Pharmaceutical Care Management Association, in which the Supreme Court unanimously ruled that Arkansas PBM regulations were not preempted by the federal ERISA law. Accordingly, NCPA says, West Virginia and other states must monitor current and future court decisions, including the upcoming PCMA v. Wehbi in the Eighth Circuit, to ensure they protect citizens from PBM abuses to their fullest authority.

“Time and time again we see PBMs manipulate the health care system to evade scrutiny, skirt reforms or maximize profits, so laws and regulations to rein them in need to be as thorough as possible,” said Karry La Violette, NCPA Senior Vice President of Government Affairs. “States like West Virginia are seeing through PBM games and passing reform legislation like HB 2263. Their patients, small business independent pharmacies, and budgets deserve these policies to be robust and fully enforced.”