The regulatory landscape of pharmacy benefits is hot with activity. When asked about our views on PBM reform and whether we are for or against it, we assess from the viewpoint of whether it is good for: 1) the public, 2) plan sponsors, and 3) MedOne.  

There are two primary happenings MedOne is closely following: SF 383 (the Iowa PBM) bill currently under review by Governor Reynolds and the Executive Order released from the White House earlier this week titled “Delivering Most-Favored-Nation Prescription Drug Pricing To American Patients.” 

Here’s what you need to know: 

Iowa’s PBM reform bill, heavily backed by the Iowa Pharmacy Association, targets and aims to combat discriminatory PBM practices, restore patient choice, and enforce adequate reimbursement to Iowa pharmacies.  

In general, MedOne is supportive of this bill as it bans spread pricing and requires 100% pass-through pricing of discounts and rebates. This bill also requires that retail pharmacies are paid a minimum reimbursement of NADAC (publicly available benchmark reflecting the average pharmacy’s acquisition cost for drugs) + a $10.68 dispense fee. Many competitors critique this provision, indicating it will lead to an increase in cost for Iowans and Iowa employers.  

When we look at our data, we see a very different picture and are not concerned; it instead showcases a win-win-win: Lower prices for Iowans and our clients, better reimbursement for independent pharmacies, and neutral to MedOne since we don’t generate revenue based on what we reimburse pharmacies. 

While we may not fully support each element of SF 383 (we view requiring copay coupons to track toward deductibles and out-of-pocket maximums as a negative for our clients), this bill is a step in the right direction, and MedOne is ready to help Iowa employers navigate and embrace this positive change.  

The general goal of the EO is ensure pharmaceutical manufacturers are offering a “most-favored-nation price” to Americans; in other words, as good as the lowest price offered in any other country, which is not the case today. The opening lines of the EO state: "The United States has less than five percent of the world’s population and yet funds around three-quarters of global pharmaceutical profits." Going on to describe this as "egregious," as the U.S. as an "unwitting sponsor," and this practice as a whole as "abuse of the Americans' generosity." This sets the stage for a targeted and toothy path forward.  

It appears many of the action items emerging from this order will fall to the Health and Human Services Secretary as the primary lead. Tasked with communicating the most-favored-nation price targets to pharmaceutical manufacturers within 30 days of May 12, we look forward to seeing these targets take shape.  

Should this prove unattainable, the Secretary is then tasked with proposing rulemaking that would (make it mandatory, not voluntary to) formally allow drug importation from developed nations with low-cost prescriptions, and/or other steps to penalize noncompliance. We expect pharmaceutical manufacturers to push back, but it is worth noting that this EO gives the Administration a path forward (in addition to significant threats). We are optimistic as it seems this effort is intended to address all Americans (not just Medicare and Medicaid programs) and would lead to lower net prices for our clients and members, alongside broader access with more pricing parity and greater simplicity for the average American. 

At this point in time, regarding both cases, we wait and we hope for more  transparent and affordable prescription drug prices for all. 

For over 25 years, MedOne has charged transparent fees for our services that we must (and do) justify in how we help our clients manage spend, care for their members, and deliver quality service. Our business model is incredibly simple, yet effective: 

   ▪️   Charge a transparent, aligned Per Member Per Month (PMPM) administrative fee where our revenue is not driven by increasing spend. 

   ▪️   Ensure appropriate use of prescriptions so you “pay for the right things" opposed to “pay for everything” or “pay for nothing.” 

   ▪️   Extend our single and best price for prescriptions to ALL clients without adjustment, while embracing innovators who can deliver even lower prices. 

   ▪️   Support members in their journey to conveniently access the most appropriate prescription at the most affordable price. 

Our business model has delivered proven results for our clients and is well-positioned for continued change across the pharmacy landscape. In fact, we welcome these types of changes when they benefit our members and clients. 

We will continue to monitor the regulatory landscape and provide material updates as they are available. If you have any questions, please contact your Account Manager.