MAC Transparency legislation introduced in Ohio!
We are pleased to report that MAC Transparency legislation has been introduced in the Ohio House of Representatives! The bill, HB 127, sponsored by Reps. Tim Brown (R-Bowling Green) and Jack Cera (D-Bellaire), intends to reign in dramatic underpayments to pharmacies by insurers and pharmacy benefit managers (PBMs). We are also pleased to report that language from HB 127 has been incorporated into the Ohio Budget (HB 64)
Specifically, here's what’s in HB 64 currently, and will soon be incorporated into HB 127 if necessary:
- Requires PBMs to be licensed as third party administrators (TPAs) by the Ohio Department of Insurance;
- If PBMs do not comply with the law, the Department of Insurance may deny the PBM's registration, refuse to renew a PBM's registration, suspend or revoke a PBM's registration, or levy fines against the PBM;
- The PBM must supply, within 10 days of a request from a pharmacy, a current list of the sources used to determine maximum allowable cost (MAC) prices;
- The PBM shall update and implement MAC pricing information at least every 7 days;
- The PBM shall provide pharmacies pricing updates that are readily available and accessible;
- To place a drug on a MAC list, it must have an A or B rating or have an NR or NA rating;
- In order for a drug to be used on a MAC price list, the drug must be generally available for purchase by pharmacies in Ohio from a national or regional wholesaler, and must not be obsolete;
- There is a 21-day limit on the right to appeal following an initial pharmacy claim;
- Appeals must be investigated and resolved by the PBM within 21 days after the appeal is made;
- A telephone number must be given for pharmacists to talk to a person about an appeal;
- Any appeal denial must have a reason given to the pharmacy for the denial, and the pharmacy must be given the NDC of the drug available to purchase at or below the set benchmark price;
- If a pharmacy successfully appeals a MAC price, the PBM must make an adjustment to a date not later than one day after the determination, and the price must be retroactive to the date the appeal was made, for the appealing pharmacy and all other similarly situated pharmacies;
- The PBM must disclose to a plan sponsor if they use the same MAC price list when billing a plan sponsor as it does when reimbursing a pharmacy;
- If the PBM uses multiple MAC price lists, the PBM shall disclose to a plan sponsor any difference between the amount paid to the pharmacy and the amount billed to the plan sponsor.
So, that’s what’s in HB 64 currently, and will soon be incorporated into HB 127 if necessary. Discussions with opponents and interested parties have been underway for months, and we’ll keep you up to date with any changes. To follow the progress of the bill and to view the text of the legislation, click here.
With generic drug prices skyrocketing, a MAC price list is only as good as it is current. If prices aren't updated regularly, and the costs of drugs increases, pharmacies can take significant losses every time they dispense certain drugs. With PBMs in the middle of an overwhelming majority of the prescription drugs dispensed to patients, the state of Ohio must put guardrails in place to ensure pharmacies and patients are treated fairly by these unregulated entities. MAC pricing impacts all Ohioans.
We need your help to get HB 127 and HB 64 through the House and Senate and then signed into law. Please contact your representative and senator, and let them know how a lack of MAC pricing standards have impacted your practice and your ability to adequately service your patients.
To learn more about MAC pricing and its impact of Ohio patients, employers, and pharmacies, OPA has created an issue brief with talking points on MAC pricing that can be accessed here.
This will not be an easy fight. We will need all hands on deck. Please consider financial support of our legislative efforts by contributing to the OPA Pharmacy PAC. 100% of Pharmacy PAC money contributed by pharmacists goes to help candidates who support pharmacy in Ohio.