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Representative Nadeau advances single-PBM model for Medical Assistance drug benefit; pharmacies urge rescue
Summary
House File 2,242 would create a single pharmacy-benefits administrator model for Medical Assistance, aiming to increase pricing transparency, stop spread pricing, and reimburse community pharmacies at or near acquisition cost plus dispensing fees.
Representative Nadeau introduced House File 2,242 to authorize a single pharmacy benefits administrator (a single PBM/PBA-style model) for the Medical Assistance (MA) pharmacy benefit. The bill’s language updates payment definitions, procurement rules for a single administrator, and seeks to stop PBM practices such as spread pricing and other nontransparent contractor fees.
Nadeau and testifiers—community pharmacists and pharmacy-aligned organizations—framed the measure as a response to “pharmacy desert” trends: independent and chain pharmacies have closed in recent years; witnesses said large shares of MA claims are reimbursed below acquisition cost under current managed care contracts. Independent pharmacists described specific transactions in which reimbursement was far below acquisition cost. Pharmacy advocates urged the committee to support a solution that reimburses pharmacies at actual acquisition cost plus a dispensing fee and to adopt a targeted bridge program (lifeline grant) while the larger change is implemented.
DHS pharmacy director and Department budget staff addressed mechanics and prior-state experience (Ohio, Kentucky and others) that used transparent acquisition-cost models and/or a single administrator. DHS described an invoice-based approach to determine actual acquisition cost and said prior deployments in other states documented material savings in some instances; DHS also noted the bill would need time to implement and that 340B protections and timing of payments affect near-term savings.
Members asked about 340B covered-entity revenues, fiscal savings and cost shifts. DHS said the model is designed to preserve 340B protections on a claim-by-claim basis, and that precise savings depend on design and timing; a fiscal note had been requested. Representative Nadeau closed urging support to stabilize pharmacy access; the committee laid the bill over as amended (DE adopted earlier) for possible omnibus inclusion.
