NCPA LDF | Key Issues

Pharmacy benefit managers were created as middlemen to reduce administrative costs for insurers, validate a patient’s eligibility, administer plan benefits, and negotiate costs between pharmacies and health plans. Over time, PBMs have been allowed to operate virtually unchecked as they consolidated to where three companies now control 80% of the prescription drug market. 

Vertical integration and a lack of transparency have led many states to enact PBM laws to address egregious business practices and level the playing field for pharmacies and patients. PBMs found ways to circumvent much of this early legislation, prompting states to revisit laws and add greater oversight and enforcement through state Departments of Insurance. 

Express Scripts, the Cigna-owned pharmacy benefit manager, continues to administer the TRICARE pharmacy benefit on behalf of the Department of Defense despite shrinking the pharmacy network by nearly 15,000 pharmacies in 2022, impacting 400,000 TRICARE beneficiaries. Adding to the patient disruption, ESI continues to list many pharmacies that were either terminated or who have voluntarily left the network due to poor contract terms as still in network. Despite these egregious errors, ESI has never been penalized or held accountable. 

The bid process for the next Tricare contract starts in 2026, and as that gets underway, bipartisan legislation has been introduced in both chambers of Congress to enhance transparency in the TRICARE pharmacy program. H.R. 6400/S. 4106, the RX ACCESS Act would restore pharmacy choice for beneficiaries, provide for fair reimbursements to pharmacies, and promote transparency and accountability of the TRICARE pharmacy program by requiring an annual audit. 

Ultimately, Tricare beneficiaries suffer when access is limited. Their choice of healthcare provider is removed, and they are forced to use mail order or drive long distances to a military treatment facility (MTF). These options are not always best for many beneficiaries. 

In 2026, NCPA played a pivotal role in helping advance Congressional passage of reasonable and relevant Medicare Part D contract reforms. We are continuing that role by convening a group of seven national pharmacy organizations to work collaboratively on implementation with CMS.  Most recently, we led our partners in filing an important memo calling on CMS leadership to take immediate action on defining these terms, which required critical expenses via Leavitt Partners.  

At the federal level, we were especially active in the PBM reforms that were passed in Congress as part of the Consolidated Appropriations Act, which included provisions directing CMS to come up with reasonable and relevant contract terms. All the while, we’ve continued to file regulatory comments to build the case for more transparent reimbursement language, limits on unilateral PBM changes, and clearer network participation protections.  

These efforts, however, are just the beginning.  

Over the next year, and with the help of our partners, we’re putting a considerable amount of time and resources into educating CMS about the issue so they can effectively draft regulations that protect independent pharmacy owners. Additionally, we’re in the process of engaging with the teams at Reed Smith and BGR Group to help ensure these terms are properly enforced. This will incur a significant investment in order to get the job done properly, and to make sure PBMs aren’t able to maneuver their way out of these obligations.  

The Alliance for Long-Term Care Pharmacy at Home convened an expert panel to describe the requirements of a pharmacy providing these services to a patient in their home, based on the CMS requirements outlined in their guidance manual for facility based patients. CMS issued the Long-Term Care Guidance on March 16, 2005 with the Medicare Drug Benefit implementation. This guidance document laid out 10 specific requirements that plans were obligated to provide for residents of LTC facilities. Long-term care pharmacy at home brings LTC facility-level of pharmacy care to individuals living at home. The Alliance has developed how these 10 requirements apply to long-term care pharmacy at home. It is the hope of the Alliance that these requirements, as outlined, became the standards by which pharmacy services to this patient population are evaluated. 

The requirements are presented in two formats, in a paragraph form in which the CMS Manual language is italicized and the non-italicized items are the Alliance guidelines for pharmacies providing LTC pharmacy at home services. In the table version, the columns are clearly identified. 

We hope that along with the criteria the Alliance has outlined for patient eligibility for these services, a comprehensive service for patients with long-term care levels of need can be effectively delivered in the home environment.