Submitting PBM Complaints
The Iowa Insurance Division (IID) has adopted and filed emergency rules pursuant to the PBM bill supported by IPA (HF 2384), which passed unanimously during the 2022 Legislative Session. These rules went into effect January 1, 2023.
The rules require PBMs to establish an internal system to collect and record information relating to pharmacy complaints. The information gathered under this system must be submitted to the Commissioner of Insurance in a Quarterly Complaint Report to ensure PBM compliance. IPA encourages pharmacies to report PBMs engaging in the conduct below to the Iowa Insurance Division:
- PBMs are prohibited from collecting direct or indirect clawbacks and transaction fees. This includes retroactively reducing reimbursement through adjustment or reconciliation, or any other means, of a clean claim.
- PBMs must adhere to maximum allowable cost (MAC) list requirements outlined under the bill. These requirements include providing reasonable access to the MAC list for in-network pharmacies, updating the MAC list within seven calendar days from the date of an increase of ten percent or more in the pharmacy acquisition cost of a prescription drug on the list or the date of a change in the methodology on which the MAC list is based, and providing a reasonable process for each in-network pharmacy to receive prompt notice of all changes to the MAC list the pharmacy is subject to.
- Additionally, for a drug to be placed on a MAC list, the prescription drug must be listed as therapeutically and pharmaceutically equivalent in the most recent orange book, it must not be obsolete or temporarily unavailable, and it must be available for purchase without limitations by all pharmacies in the state from an Iowa-licensed national or regional wholesale distributor.
- A pharmacy benefits manager shall not mandate basic record keeping that is more stringent than that required by state or federal law or regulation.
IPA members should submit complaints of PBM violations to IID using this form.
Questions? Please contact Seth Brown (firstname.lastname@example.org) or Brett Barker (email@example.com).