Are PBM Regulations Being Enforced by Your State? Let Your Voice Be Heard!

When PBMs violate state law, pharmacies need to scream from the mountain tops. Get the ball rolling by filing a complaint with your state regulators. As a local state representative said, “If there are no complaints, then we assume all of the regulations put forth are working great”. If you’re not sure where to start, the National Community Pharmacists Association’s (NCPA) has a webpage that provides instructions on how to file a complaint in your state.

Over the past several years, nearly every state has passed some type of PBM reform. While there have been great strides with comprehensive regulations, and court victories, this can be diminished if no complaints are reported [when laws are violated] and states are not held accountable for enforcing the laws being put in place.

You must be proactive and hold your state agency’s feet to the fire. You do that by filing complaints when the insurers/PBMs are NOT following the law. It surely does not shock any community pharmacy that PBMs willing violate these laws. The more detailed, factual-based complaints regulators receive, the more likely they are to investigate and ENFORCE the law.

Not only does failing to report violations undermine the effort that went into getting the law passed, but it also makes future PBM reform more difficult. With minimal complaints on record, legislators (and PBM lobbyists) may use that as rationale not to take up additional reform (i.e., the existing regulations are effective).   

Some of the common complaints with audits are:

  • Failure to adhere to audit timelines or limitations
  • Identifying audits as FWA or ‘investigational’ seemingly only to avoid state audit parameters
  • Auditors refusing to accept documentation
  • Inconsistent application of audit rules and guidelines
  • Recoupments for technical discrepancies

Pharmacies are often fearful of filing complaints due to the potential for PBM retaliation. Consequently, many states have included non-retaliation language in the reform. While it can understandably give pharmacy owners pause, if you’re not willing to stand up for your pharmacy, who will?

PAAS Tips:

  • Be familiar with your state PBM regulations
  • If you feel state laws have been violated – file a complaint
    • Unsure of whether an audit situation is complaint worthy? Talk with PAAS
    • Provide all necessary documentation to support (and explain) your dispute
    • Maintain thorough documentation of all pharmacy transactions and interactions relevant to the situation
Kristen Sterzinger, CPhT
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