Healthcare leaders discussed efforts that aim to increase access to prescription drugs and lower their costs during the 2023 Florida State of Reform Health Policy Conference a couple weeks ago.
Florida Association of Community Health Centers Vice President and COO Ben Browning said consumers scored a big victory with the legislature’s passage of House Bill 1509, which takes several steps to regulate pharmacy benefit managers (PBMs).
“There were a lot of people that had to contribute their strength, their power, and their influence to get that bill over the line,” Browning said. “We at the association have been working with the legislature for six years, if not longer, to try and get something on the books. Over the years, there have been little pieces along the way. This year, the governor got behind it. He had an executive order over the summer. It kind of laid the groundwork for this bill.”
Many pharmacists said PBM business practices were hindering their ability to provide needed medications for Floridians during testimony for HB 1509 and its companion bill, Senate Bill 1550, during the legislative session.
“I’m hoping it’s not the end of the line for PBM reform,” Browning said. “They play a significant role in the healthcare industry. However, their role has changed and evolved over the years, so it’s good to see some of the guardrails and protections for patients that the legislature was able to put in place. There is a section in (HB 1509) on price transparency for manufacturers so if the price of a drug goes up a certain percentage, they have to explain why. So that information can be more transparent.”
The bill aims to prevent spread pricing, which occurs when PBMs are reimbursed a certain price for a drug by an insurer or employer, but pays pharmacies a lower price to dispense the drug.
“Instead of that rebate from the manufacturer going to the PBM, it now has to be passed directly to the plan,” Browning said. “What the plans say they do with those dollars is lower the premiums. So we’re all really excited to see everybody’s premiums go through the floor because these rebates are quite significant.”
HB 1509 also aims to prevent patient steering, a practice in which PBMs deny pharmacies access to their networks (through credentialing denials or terminations) following adverse audit findings to steer patients toward PBM-owned pharmacies for their drugs.
“There’s another section that prohibits steering,” Browning said. “You cannot exclusively send patients to the PBM’s pharmacy. You have to have an opportunity for other pharmacies to be a part of the network. This is great for competition. Pharmacists are being put out of business by the thousands because they’re not able to compete. They’re not able to gain access to the network.”
The bill also requires PBMs to identify ownership affiliations, and provides requirements for contracts between PBMs and pharmacies.
“There are so many good pieces to this bill, so many different ways they’re expanding access to patients and to the other pharmacies in this state,” Browning said. “You can put in penalties, you can put in fines, you can put in some sort of repercussions for violating any piece of that legislation.”
Stephanie Hengst, manager of policy and research at The AIDS Institute, said the federal $2,000 cap on out-of-pocket Medicare drug costs that will start in 2025 will have a significant impact on drug cost savings for Floridians.
“Even though we represent people with HIV, a lot of our work can apply to other patients with serious conditions,” Hengst said. “A lot of the policy activity we focus on is addressing out-of-pocket costs. The out-of-pocket cap in Medicare is phenomenal. We’ve been advocating for that for a long time. A $2,000 cap would be welcomed, especially for people over 65. They’re often on a fixed income. That will be really helpful for people with HIV.”
Hengst said she hopes the state can make a push toward Medicaid expansion in the future. Florida is one of only 10 states that has not expanded its Medicaid program under the Affordable Care Act to adults ages 19-64 with incomes under 138% of the federal poverty level.
“The common conversation today is the lack of Medicaid expansion in the state,” Hengst said. “There are a lot of people with serious conditions, including HIV, who would benefit from Medicaid expansion. We’re still hopeful that in future years there could be a ballot initiative that would help bridge that gap for a lot of people.”