Preserve Patient Access to Neighborhood Pharmacies

Studies and Data

AHCA Commissioned Analysis of FL Medicaid Confirms Over $90Million in PBM Spread Pricing

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This recent independent analysis of Florida Medicare commissioned by the Agency for Health Care Administration (ACHA) sheds light on PBM fee and pricing practices in Florida's Statewide Medicaid Managed Care System (SMMC). The analysis confirms that PBMs have taken over $90 Million per year in excess profits through the use of spread pricing.

Legislative Leaders are Calling for Action

“Markets fail when markets get corrupted and that is what has happened here. When the middleman is allowed to own the end-retailer then the middlemen’s incentive to manage cost appropriately for the benefit of the chain is broken. And that is what has happened here.”

-- Rep. Randy Fine

“The power and control of PBMs has grown significantly over the last five to ten years. What we’re seeing is insurance companies owning PBMs and PBMs owning insurance companies. What is happening in the long run is that the price of prescriptions are going up.”

-- Sen. Gayle Harrell

“The practices PBMs use to drive up profits are complex, but the solution is simple: We need to increase access to care for all Floridians while ensuring that prescription drug savings make it to the patient and not the pockets of predatory PBMs.”

-- Rep. Jackie Toledo

When it comes to PBMs,
we all pay the price.

Pharmacy Benefit Managers (PBMs) are middlemen who have strayed from their original purpose of negotiating savings for patients and now keep the profits for themselves, leaving the rest of Florida’s consumers to pay higher drug prices. PBMs use anti-competitive practices to short-circuit the free market and create health care monopolies.

These predatory tactics decrease access for patients, force neighborhood pharmacies to close down, and raise costs for everyone. We need legislation that will increase transparency and accountability on PBMs and ensure that patients are prioritized over profits.

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Who do PBM predatory tactics hurt?

Patients

Forcing neighborhood pharmacies out of PBM health networks causes many patients to drive extra miles from their home to receive medications simply because their local pharmacy is not in their plan. This not only steers business away from neighborhood pharmacies, it severely restricts patients’ access to medications and drives up their costs.

Pharmacists

Many neighborhood pharmacies diligently refill prescriptions only to be hit with reimbursements that are pennies on the dollar – with some even facing negative reimbursements or clawbacks – while PBMs continue to make record-breaking profits. No business can sustain operations under this model, and it is a clear manipulation of the system that promotes anti-competitive practices.

Providers

PBMs are overstepping their scope and making medical decisions best left to physicians and pharmacists – and their years of training. PBMs are motivated by profit, not by what is best for the patient, and many times PBMs require the use of drugs or specialty medications that are not the most beneficial for the patient.

Payors

The anti-competitive policies that PBMs push increase health care costs for everyone. PBMs don’t make or provide the drug – they don’t even touch the drug – yet they add costs to the overall health care system that must be absorbed by pharmacists, patients, and all Floridians.

How Can We Fix This?

This year, the Florida Legislature is considering legislation to address these challenges. SB 1444 and HB 961 implement transparency, accountability, and free-market policies that will help preserve patient access and keep drug prices affordable.

Here are some highlights of the legislation:

Protect the free market by prohibiting anti-competitive policies that reduce patient choice and create health care monopolies
Eliminate the practice of steering patients to PBM-owned pharmacies, especially when it involves taxpayer dollars
Prohibit the predatory practices that PBMs use to squeeze independent pharmacies, including post-adjudication fees, spread pricing, and cumbersome audit practices

By supporting this legislation, we can bring about concrete change in the industry and put a stop to the abuses that leave Floridians suffering.

News

Proposed Medicaid Pharmacy Legislation Could Help Bridge the State Budget Gap While Preserving Patient Access and Choice of Pharmacy

Representative Randy Fine, co-sponsor Rep. Jackie Toledo, and Senator Ana Maria Rodriguez recently announced the details of new proposed legislation that could save the State of Florida as much as $200 million per year while also expanding the Florida Medicaid pharmacy network and access to medication for the state’s anticipated 4.4 million Medicaid recipients. HB 1043 and SB 1306 are bills that would “carve out” pharmacy coverage from the Statewide Medicaid Managed Care system. They call for the end of systemic overpayments to the pharmacy benefit manager (PBMs) middlemen currently overseeing Medicaid pharmacy, as uncovered in the state-funded Milliman Florida Medicaid report released last November. These overpayments — amounting to somewhere between […]

FL Pharmacy Groups Fight PBMs with HB 1043

Florida pharmacy advocacy group Small Business Pharmacies Aligned for Reform (SPAR) and national advocacy group Pharmacists United for Truth and Transparency (PUTT) counseled with Republican and Democrat state representatives to advocate for HB 1043’s passage. HB 1043, titled, “Medicaid Pharmacy Benefit Savings” would require: “AHCA to select single pharmacy benefit administrator through competitive procurement process by specified date; provides contract requirements; requires agency to calculate amount equal to specified percentage of managed care organization’s net underwriting gain for certain contract year & reduce organization’s contract term payment by such amount.” The sponsor of the bill, Rep. Randy Fine (D-53) claims that with this bill, “there will be losers”, however, “the […]

Republicans look to curb prescription middlemen’s fees and practices

Florida Politics A recent report shows that Pharmacy Benefit Managers could be costing the state hundreds of millions. A band of Republican lawmakers hope to reel in pharmacy benefit managers and save Florida’s Medicaid program millions of dollars. They say their legislation (SB 1306/HB 1043) would level the playing field to contest unfair practices by pharmacy benefit managers, known as PBMs. In doing so, one sponsor, Doral Sen. Ana Maria Rodriguez, said the state could save at least $143 million in the bill’s first year. “Our pharmacies are being gouged for providing services to communities that would otherwise be left no choice and they’d suffer […]

Bills seek to save Florida Medicaid hundreds of millions of dollars, improve prescription drug care for patients

The Capitolist Pharmacy advocacy groups gathered with Florida senators and representatives to discuss bills before the legislature designed to save the state millions of dollars and protect local pharmacies at a press conference today. Florida pharmacy advocacy group Small Business Pharmacies Aligned for Reform (SPAR) and national advocacy group Pharmacists United for Truth and Transparency (PUTT) were joined by Representative Randy Fine (R-District 53), Representative Jackie Toledo (R-Distirct 60), Senator Gayle Harrell (R-District 25), Senator Tom Wright (R-District 14), and Senator Ana Maria Rodriguez (R-District 39) at the State Capitol. HB 1043, sponsored by Fine and SB 1306, sponsored by Rodriguez, aim to move Florida Medicaid to a pharmacy fee-for-service model. If enacted, the move […]

Marco Rubio Backs Jeanne Shaheen’s Proposal to Reduce Prescription Drug Prices

Florida Daily Last week, U.S. Sen. Marco Rubio, R-Fla., backed U.S. Sen. Jeanne Shaheen’s, D-NH, “Ensuring Timely Access to Generics Act.” The bill “would tackle exorbitant prescription costs by increasing competition for generic drugs through better oversight of the Food and Drug Administration’s (FDA) citizen petition process.” “This legislation ensures the FDA’s ability to reject citizen petitions if they believe that the primary purpose of the petition is to delay the approval of an application, thereby increasing competition in the marketplace and lowering costs for patients. The bill would also set a time limit to ensure that citizen petitions are submitted in a timely manner after the […]

In letter to AHCA, EMPOWER Patients says PBM reform could save $100M

Florida Politics EMPOWER Patients sent a letter to new Agency for Health Care Administration Secretary Simone Marstiller on Friday apprising her of the taxpayer dollars going to pharmacy benefit managers, or PBMs. EMPOWER Patients is a coalition made up of neighborhood and independent pharmacists and pharmacies advocating for PBM reform. PBMs are middlemen between health care plans and pharmacies. They help determine which drugs will be covered by insurance plans and negotiate on behalf of insurers to secure discounts from drug manufacturers. When a claim is filed, PBMs collect money from those plans, then pass money to pharmacies via different methods. The letter comes after a recent hearing in the […]