It’s been a tough year for community pharmacy in its fight to regulate PBMs in the states. The victories were hard fought and the losses often brutal. This is NCPA’s review of PBM legislation in 2024, with a focus on reimbursement.
This year, there were fewer PBM-related bills introduced compared to recent years. NCPA monitored approximately 225 bills across 48 states in 2024, compared to over 400 bills in 2023. However, one could argue the current bills, many of which sought reimbursement floors, were more challenging to enact than other types of PBM reform legislation. The sheer amount of PBM lobbying power and new, unsavory tactics that they now use to oppose reimbursement floor legislation suggest that pharmacy advocates are now touching PBM nerves on a whole new level.
This year, huge reimbursement victories were achieved in Kentucky with S.B. 188 and in West Virginia with S.B. 453. The Kentucky bill created a reimbursement floor of NADAC plus a professional dispensing fee based on the Medicaid fee-for-service cost to dispense for both the commercial market and for plans serving state employees. West Virginia’s S.B. 453 brought the “NADAC-plus” floor to its Public Employee Insurance Agency, adding onto its previous requirement for NADAC-plus in the commercial space.
On the flip side, pharmacy advocates seeking reimbursement floors were dragged through the mud in states such as Alabama and North Carolina. Bill sponsors were trashed in social media, pharmacy-owning legislators were targets of efforts to drive business away from their stores, and grassroots efforts were spawned to paint dispensing fees as new taxes and increased health care costs. It was hard to watch people (and likely bots) doing the bidding of Fortune 20 companies by railing against small businesses just looking to stay open.
Pharmacy advocates learned hard lessons from taking these lumps and NCPA is working on resources to help its members and partners combat these hideous PBM tactics in 2025. In total, commercial market reimbursement floors of NADAC-plus are now law in Kentucky, Tennessee, and West Virginia.
Arkansas has a requirement to use NADAC but has lacked a required dispensing fee, something PBMs took advantage of. However, Emergency Rule 128, which kicked in last month, now requires PBMs to provide fair and reasonable reimbursement. It gives the Office of the Insurance Commissioner the power to approve or deny PBM reimbursement schemes.
Unfortunately, a state employee plan floor bill, S.B. 198, made it to the governor’s desk in Georgia with strong legislative support but received a contentious veto. This was despite Georgia advocates proving the state was needlessly paying chains more than independents using pricing data from the state health benefit plan website. NCPA anticipates more legislative activity in the state employee health plan market moving forward.
Please read NCPA’s 2024 State Wins for Community Pharmacy to learn about other PBM legislative and regulatory victories. We’ll be updating it soon to include some exciting late-breaking victories. Meanwhile, PBM enforcement continued to gain momentum as a key issue for NCPA and its members and partners in the states—stay tuned for a recap of those efforts in the coming weeks.
