Radar on Drug Benefits

A year after it was enacted, Florida’s PBM reform law is causing compliance headaches for employers and PBMs alike. 

The Prescription Drug Reform Act (PDRA), which took effect in January 2024, requires PBMs to eliminate spread pricing and pass 100% of manufacturer rebates to plan sponsors, and it forbids requiring enrollees to fill medications by mail order, among other provisions. But the law also requires employers to submit a one-page attestation acknowledging that the PBM is complying with the law — a requirement that can place a substantial burden on employers. 

What’s more, Florida’s Office of Insurance Regulation (OIR) in February requested large amounts of sensitive patient data from PBMs, Bloomberg first reported. The request includes information on all prescriptions filled in Florida in 2024, even by nonresidents, including patient names and medications, raising serious privacy concerns. 

A Minnesota district court judge on March 24 dismissed a lawsuit brought last year by former Wells Fargo & Co. employees alleging the company violated the Employee Retirement Income Security Act (ERISA) by paying more than it should have for prescription medications. The ruling occurred two months after a district court judge in New Jersey dismissed similar claims that a Johnson & Johnson employee made against her employer, saying she lacked standing to bring the case. 

However, the plaintiff in the Johnson & Johnson case on March 10 filed an amended complaint with the court and added another plaintiff. The re-filing “enhanced the allegations with respect to what the harm is to the plaintiff,” says Joanne Roskey, an attorney with Miller & Chevalier who is not involved with the case. Roskey expects Johnson & Johnson to seek another motion to dismiss in the next few weeks challenging the amended allegations. 

The America First Policy Institute, a think tank founded by former advisers to President Donald Trump, recently released a paper that blamed foreign countries for pharmaceutical “global freeloading” and outlined several policy options to end it. Options included most-favored nation pricing and international reference pricing — two proposals raised during Trump’s first term.

The paper argued that this pharmaceutical freeloading occurs when other wealthy countries implement price controls that allow them to “have their cake and eat it too — to get lifesaving drugs for their citizens without paying the necessary costs to develop them.” It deprives drug manufacturers of billions of dollars and comes at the cost of new treatments for patients in the U.S. and abroad, the paper said.

Optum Rx’s new pharmacy reimbursement model, which the UnitedHealth Group-owned PBM unveiled on March 20, has been met with mixed reviews. One Wall Street analyst suggested the move could benefit both Optum and retail pharmacies alike, but a trade group representing community pharmacies was far more wary. 

Whatever the ultimate impact is, the motivation for such a move is clear, says Ge Bai, Ph.D., a business and health policy professor at Johns Hopkins University.  

“PBM reform is on policymakers’ radar,” she tells AIS Health, a division of MMIT. “Optum seems to be taking a preemptive step to align with what might soon be mandated.” 

New uses for GLP-1 drugs, the proliferation of artificial intelligence (AI), and federal and state regulatory changes are among the top issues for managed care pharmacy over the next five years, according to a study from the Academy of Managed Care Pharmacy (AMCP). 

“Anything that can replace manual tasks to allow the pharmacist to practice to the level of their license with their skill set and counsel patients on their medications and really work with them [is a plus],” AMCP Foundation Executive Director Mitzi Wasik tells AIS Health, a division of MMIT. AI “has really taken some of the manual burden off of the pharmacist. They are really trained to practice at a high skill set of patient care. A lot of times in the community setting, they just don’t have the capacity to do it.”