§1320b–23 Pharmacy Benefit Managers Transparency Requirements

Summary

Health plans and companies that run prescription drug benefits for those plans (called PBMs) must give certain drug-use and price information to the federal Secretary. This applies when they manage coverage for prescription drug plans or Medicare Advantage drug plans under part D, or for qualified health plans sold on a State exchange under section 18031. PBMs must also give the same information to the plan that hires them. They must report, for each contract year, how many prescriptions came from retail versus mail-order pharmacies and the rate generics were dispensed by pharmacy type; the total amount and kinds of rebates, discounts, or price concessions the PBM negotiated that relate to plan use (not including bona fide service fees like distribution fees, inventory fees, stocking allowances, admin service fees, or patient-care program fees), how much of those savings were passed on to the plan, and the total prescriptions; and the total difference between what the plan paid the PBM and what the PBM paid pharmacies, plus prescription counts. The information is confidential, but the Secretary may share it in de-identified form to carry out the law, and with the Comptroller General, the Director of the Congressional Budget Office, and States for their duties under section 18031. If a plan or PBM fails to provide timely or knowingly gives false information, penalties under subsection (b)(3)(C) of section 1396r–8 apply in the same way they apply to manufacturers with agreements.