|Posted:||June 30, 2015 11:52 AM|
|From:||Representative Matthew E. Baker and Rep. Florindo J. Fabrizio|
|To:||All House members|
|Subject:||Co-sponsor Pharmacy Benefit Manager (PBM) Registration/Maximum Allowable Cost List (MAC) Transparency and Pharmacy Audit Integrity Legislation|
|Please join us in co-sponsoring a package of bills we will be introducing in the near future to require PBMs to register with the Department of Health and provide maximum allowable cost (MAC) list transparency to pharmacies and to create a Pharmacy Audit Integrity Act to protect pharmacies from unfair auditing practices.
PBMs serve as middlemen between payers and pharmacies – and manage the pharmacy benefits for nearly 95% of all Americans with medical coverage. However, in Pennsylvania, PBMs do not have to register with any state agency or department. The first bill would establish basic registration requirements and will provide the avenue for oversight and require some accountability.
In addition, the bill would require PBMs to provide pharmacies with how MAC list pricing is determined and updated and establish an appeals process in which a pharmacist can contest a listed MAC price. A MAC list refers to an generated list of medications for which a MAC has been established by a PBM. Each PBM establishes its own MAC list or lists and sets the maximum amount they will reimburse a pharmacy, without regard to the price at which pharmacies may purchase the drug. More and more these established prices are below a pharmacy’s acquisition cost and creating a financial burden for the pharmacy.
The second bill would create a Pharmacy Audit Integrity Act to protect pharmacies from unfair auditing practices. Currently, no oversight or procedural requirements are in place for the audits performed on pharmacies in Pennsylvania.
This legislation would specify procedures for auditing pharmacy records by PBMs. Among the procedures implemented include: providing the pharmacy with adequate notice prior to conducting an on-site audit, that audits must be conducted applying only the applicable Federal or Commonwealth of Pennsylvania laws and regulations and allowing for a specific appeal and review process. Additionally, extrapolation audits, which assess final audit results based only on a sample size, would be specifically prohibited.
This proposed legislation does not prohibit audits from occurring. In fact, it allows for full recovery of finances in any case where fraud or abuse has occurred. It simply sets reasonable standards for fair and uniform audit procedures. These standards would protect pharmacies from being burdened with costly penalties in cases where no fraud or financial loss has occurred and where a simple clerical or typographical error was the only mistake made.
We hope you will join us in co-sponsoring these important bills. Thank you for your interest and support.
Introduced as HB947
|Description:||The first bill would establish basic registration requirements and will provide the avenue for oversight and require some accountability.
Introduced as HB946
|Description:||The second bill would create a Pharmacy Audit Integrity Act to protect pharmacies from unfair auditing practices. Currently, no oversight or procedural requirements are in place for the audits performed on pharmacies in Pennsylvania|