Congress is leaving out significant opportunities to reform prescription drug pricing in Medicaid Managed Care in the proposed Build Back Better Act, according to officials with American Pharmacy Cooperative, Inc. (APCI).

Early discussions of the bill considered language that would end the practice of “spread pricing” by pharmacy benefit managers (PBMs) and Medicaid Managed Care Organizations (MCOs) in Medicaid. This is a practice where these middlemen charge an insurer one price for a prescription drug, reimburse the dispensing pharmacy a lower amount, and keep the difference. This language did not make it into the current version of the bill.

APCI CEO Tim Hamrick offered the following statement: 

“The Build Back Better Act afforded an opportunity to implement real change in America’s Medicaid managed care system by ending PBM prescription drug spread pricing games, increasing transparency, and reimbursing community pharmacies fairly. Implementing these changes would have saved taxpayers $1 billion in federal spending alone while bolstering America’s community pharmacies that care for some of this country’s most vulnerable patients.”

Added APCI’s Director of Legislative Affairs Bill Eley:

“The unwillingness to tackle Medicaid managed care prescription drug reform in the Build Back Better Act is curious with PBM and MCO abuses front and center. States have uncovered hundreds of millions of dollars in prescription drug overcharges by PBMs and MCOs in the Medicaid managed care system. One of the nation’s largest MCOs has already paid out over $200 million to settle investigations in four states. The lack of action also comes on the heels of an explosive hearing in Ohio exposing continued problems with PBM/MCO prescription drug practices with the state’s Medicaid chief conceding PBM clawbacks ‘skew the entire economic dynamic [in Medicaid managed care].’”

APCI remains committed to Medicaid managed care reform and working with Congress at the federal level as well as state general assemblies to put a stop to the cycle of abuse. Greg Reybold, APCI’s Director of Healthcare Policy concluded:

“Unfortunately, many MCOs and PBMs have grown fat feeding off America’s patients, community pharmacies, and taxpayers by exploiting prescription drug pricing and steering patients to MCO and PBM affiliated pharmacies. APCI will continue its fight for Medicaid managed care reform and to hold PBMs and MCOs accountable. The system must be fixed.”