Ama Policy

The Impact of Pharmacy Benefit Managers on Patients and Physicians D-110.987

Step Therapy Override

1. Our AMA supports the active regulation of pharmacy benefit managers (PBMs) under state departments of insurance.

2. Our AMA will develop model state legislation addressing the state regulation of PBMs, which shall include provisions to maximize the number of PBMs under state regulatory oversight.

3. Our AMA supports requiring the application of manufacturer rebates and pharmacy price concessions, including direct and indirect remuneration (DIR) fees, to drug prices at the point-of-sale.

4. Our AMA supports efforts to ensure that PBMs are subject to state and federal laws that prevent discrimination against patients, including those related to discriminatory benefit design and mental health and substance use disorder parity.

5. Our AMA supports improved transparency of PBM operations, including disclosing:

– Utilization information;

– Rebate and discount information;

– Financial incentive information;

– Pharmacy and therapeutics (P&T) committee information, including records describing why a medication is chosen for or removed in the P&T committee’s formulary, whether P&T committee members have a financial or other conflict of interest, and decisions related to tiering, prior authorization and step therapy;

– Formulary information, specifically information as to whether certain drugs are preferred over others and patient cost-sharing responsibilities, made available to patients and to prescribers at the point-of-care in electronic health records;

– Methodology and sources utilized to determine drug classification and multiple source generic pricing; and

– Percentage of sole source contracts awarded annually.

6. Our AMA encourages increased transparency in how DIR fees are determined and calculated.

Policy Timeline
CMS Rep. 05, A-19