The Bridge    Join    

PBM Enforcement

IPA continues to work closely with the Iowa Legislature and Iowa Insurance Division (IID) regarding regulation of PBMs. While IID continues to investigate and update their PBM rules, IPA encourages pharmacies to submit formal complaints of wrongful PBM practices.

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.

Since passage of PBM legislation in 2014, PBMs have been required to submit Quarterly Reports; however, the Iowa Insurance Division (IID) did not have a standard format for the reports, so PBMs had free reign in submitting any information they deemed adequately responded to the reporting requirement. With the passage of HF 2384, the IID received funding for two new staff positions, to devote to oversight of PBMs. With staff dedicated to PBM oversight, IID standardized the quarterly reporting process for optimum analysis and enforcement.

IPA members should submit complaints of PBM violations of Iowa Code 510B or Iowa Administrative Code Chapter 59 to IID using this form.

It is a best practice to complete the PBM’s internal complaint process prior to submitting an unresolved complaint to IID.

Pharmacists should also encourage patients, consumers and prescribers that are negatively impacted by PBM practices to submit complaints using the same 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:

  • 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.  


Click here for frequently asked questions on submitting complaints.

More Information

BOP: What, Why & How Podcast – For an in-depth discussion of these rules, listen to the December 2022 BOP: What, Why & How podcast. In addition, watch for an upcoming Special Edition episode on the process and examples of submitting complaints.

Contact IPA’s Director of Public Affairs, Seth Brown, or Senior Policy Advisor, Brett Barker, with additional questions.

*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.