PBM Enforcement
IPA continues to work closely with the Iowa Legislature and Iowa Insurance Division (IID) regarding regulation of PBMs. To enact effective PBM reform at the state level, ample data must be provided to state regulators to uncover abusive PBM practices. IPA encourages pharmacies to submit formal complaints of wrongful PBM practices.
IPA members should submit complaints of PBM violations of Iowa Code 510B or Iowa Administrative Code Chapter 59 to IID using this form.
Iowa Code requires 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:
Please note: This only applies to commercial plans and does not cover Medicare Part D or Medicaid.
- 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.
- Contract provisions between PBMs and pharmacies or PSAOs that entail the PBM reviewing the aggregate claims paid to network pharmacies and retroactively reducing payments made on those pharmacy claims are prohibited. Therefore, effective Rate reimbursement models including, but not limited to, “brand effective rates,” “generic effective rates,” or “dispensing fee effective rates,” should be reported to IID.
- 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 requirements more stringent than that required by state or federal law or regulation.
Multiple Claims or Attachments
Opening a complaint will trigger an IID investigation, and IID staff will reach out for additional information. Supporting documents such as PBM appeals, spreadsheets, claim reports, etc., can be submitted to IID at that time. Complaint information submitted to the Division is confidential, and retaliation from PBMs is strictly prohibited.
IPA continues to work with IID to adjust the complaint form for ease of submission.
Pharmacists should also encourage patients, consumers and prescribers that are negatively impacted by PBM practices to submit complaints using this form. IPA created this resource to print and distribute in your pharmacy to help educate patients on PBM's impact on their health.
A Decade of PBM Efforts
Click here for a full timeline of Iowa PBM regulation.The Iowa Insurance Division (IID) adopted and filed emergency rules pursuant to the PBM bill championed by IPA (HF 2384), which passed unanimously during the 2022 Legislative Session. HF 2384 became effective upon enrollment on June 13, 2022.
The resulting emergency rules went into effect January 1, 2023.
FAQ
Click here for frequently asked questions on submitting complaints.
More Information
What, Why & How Podcast – For an in-depth discussion of these rules, listen to the December 2022 What, Why & How podcast.
*Note – Pharmacy pricing data is confidential and may not be shared with the Iowa Pharmacy Association (IPA) or between IPA members. This information can be used by pharmacies in communicating with their PSAO, the PBM, or the Iowa Insurance Division. Do NOT send or share pharmacy pricing information with the Iowa Pharmacy Association, as it could be a violation of federal anti-trust laws.
