§1320b–23 Pharmacy benefit managers transparency requirements

Summary

Health plans and companies that run drug benefits for Medicare Part D plans or for plans sold on a state insurance exchange must give yearly reports about how they handle prescriptions. They must say what share of prescriptions went to retail versus mail-order pharmacies and the share filled with generics by pharmacy type (like independent, chain, supermarket, or big-box stores). They must report the total rebates, discounts, or price concessions they negotiated that come from patient drug use, how much of those were passed to the plan sponsor, and how many prescriptions were filled. They must also report the total difference between what the plan paid the PBM and what the PBM paid pharmacies, and the number of prescriptions involved. Small service fees (for things like distribution, inventory, stocking, admin services, or patient programs) are not counted as those rebates. The reports are private. The Department may share versions that do not identify a specific plan, PBM, or drug prices when needed to do its job, and may give de-identified data to the Government Accountability Office, the Congressional Budget Office, and States for running exchanges. If a plan or PBM misses the deadline or knowingly gives false information, it faces the same consequences that apply to drug manufacturers under the referenced rule. Definitions: PBM — a health plan or company that manages prescription drug benefits for a plan.