APhA: Pharmacist care coverage omitted from PBM reform

WASHINGTON — Congress has approved a federal funding package that includes long-sought pharmacy benefit manager (PBM) reforms supported by the American Pharmacists Association, marking a major step toward stabilizing Medicare pharmacy reimbursement. The bill is expected to be signed into law.

Congress passes PBM reform as part of spending package

The legislation now goes to the White House, where President Trump is expected to sign it into law.

Chain Drug ReviewCDR

APhA welcomed the PBM provisions as meaningful progress but sharply criticized lawmakers for failing to include legislation that would enable Medicare to cover pharmacist-provided patient care services, including H.R. 3160, the Ensuring Community Access to Pharmacist Services Act.

“While these reforms begin to address one of the most significant challenges pharmacists face under Medicare, they represent only part of what’s needed,” said APhA Executive Vice President and CEO Michael D. Hogue, PharmD. “To truly improve health care delivery, Congress and Medicare must also recognize and pay for the patient care services that pharmacists provide every day.”

What the PBM reforms do

The enacted provisions focus on improving transparency and fairness in Medicare Part D and include:

• Pharmacy fairness and access standards: CMS must define and enforce transparent Part D contract terms, with standards due by 2028 and implementation starting January 1, 2029. Protections ensure that any willing pharmacy that meets the plan’s terms can participate in the network.
• Delinking PBM compensation from list prices: Beginning in 2028, PBMs will shift from price-based compensation to service-based payments, aimed at improving alignment and transparency in Medicare drug plans.
• Expanded oversight: Congress directed the Government Accountability Office and the Medicare Payment Advisory Commission to evaluate PBM practices across Medicare Part D and Medicare Advantage–Prescription Drug plans, including impacts on pharmacy reimbursement and beneficiary out-of-pocket costs.

What’s missing, APhA says

Despite the PBM reforms, APhA stressed that the legislation stops short of fully modernizing pharmacy payment policy. The association argues that without Medicare coverage for pharmacist-delivered preventive and clinical services, community pharmacies will remain financially strained and patients will miss out on lower-cost care that can reduce hospitalizations and overall health spending.

“These reforms are an important first step,” Hogue said, “but lasting progress requires valuing pharmacists not only as dispensers of medications, but as front-line health care providers.”

APhA said it will continue to press Congress and federal agencies to advance coverage of pharmacist services as the next phase of pharmacy payment reform.