June 26,2024

Wyden Calls for Action to Stop PBM Middlemen from Flagrantly Flouting Medicare Rules that Protect Pharmacies

Amid Reports of PBM Games that Force Pharmacies to Financial Brink, Finance Chairman Calls on CMS to Increase Enforcement and Oversight

Washington, D.C. – Senate Finance Committee Chair Ron Wyden, D-Ore., today called on the Centers for Medicare & Medicaid Services (CMS) to step up oversight and enforcement of Medicare Part D program requirements for pharmacy benefit managers (PBMs) that protect pharmacies from unfair contracting practices.

“I am alarmed to hear reports that PBM contracting practices are straining the finances of pharmacies and directly contributing to their closures,” Wyden wrote. “Specifically, I am concerned PBMs are not adhering to the new rule reining in direct and indirect remuneration (DIR) fees that took effect on January 1 and undermining Medicare’s pharmacy access standards as intended by Congress. Local pharmacies not only provide access to prescribed medication, they also play an essential role in delivering critical patient services such as patient education, management of chronic illness, and preventive care.”

The letter outlines several actions that CMS could immediately take using the Medicare statute to enforce these rules, including:

  • Enforce “Any Willing Pharmacy” requirements by ensuring that PBMs reimburse pharmacies at a minimum of the cost to acquire and dispense covered prescription drugs.
  • Enforce, such as through auditing, the pharmacy price concessions provision included in the Medicare Program; Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs; Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency; Additional Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency final rule that requires all pharmacy price concessions be applied to negotiated prices at the point of sale under Part D.
  • Implement standardized pharmacy measures which are long overdue, including the evaluation and reporting of plan performance measures which CMS has finalized in rulemaking yet has not fully come to fruition.
  • Review formal or informal complaints about PBM contracting practices under Part D received over the past 18 months to determine if the number of complaints is higher than in prior years.
  • Respond to this letter with information, within 60 days, on the number of formal or informal complaints received about PBM contracting practices over the past 18 months, a description of the type of complaints received, and the disposition of the complaints.      

Wyden previously supported CMS finalizing the rules protecting pharmacies.

The full letter can be found here.

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