[{"_1":2,"_112":-5,"_113":-5},"loaderData",{"_3":4,"_26":27},"root",{"_5":6,"_17":10,"_18":19,"_20":21,"_22":10,"_23":-5,"_24":-5,"_25":10},"user",{"_7":8,"_9":10,"_11":10,"_12":-5,"_13":-5,"_14":15,"_16":-5},"roles",[],"isAuthenticated",false,"isPremium","planName","subscriptionStatus","featureFlags",{},"insightsBudget","isDevelopmentHost","userPreferences",{},"recaptchaSiteKey","6LcvOJcUAAAAAHsB-gPGfGktcRlKpH7OTIU_dMTD","isImpersonating","impersonation","affiliateStatus","isFreedomPortal","routes/v2/article/layout",{"_28":29,"_30":31},"notFound",true,"relatedArticles",[32,76,88,100],{"_33":34,"_35":36,"_37":38,"_39":40,"_41":42,"_43":44,"_45":46,"_47":48,"_49":50,"_51":52,"_53":54,"_55":56,"_57":58,"_59":60,"_61":62,"_63":64,"_65":66,"_67":68,"_69":70,"_71":72,"_73":74,"_75":74},"mediaId",6104182,"mediaKeyId","2792267-e57b05283d073e6b73c60e394ee37cbf","parentId",2792267,"title","Lawmakers Hear Competing Views on PBMs’ Role in Drug Prices and Formularies","audioSeconds",1077,"startMs",207165,"endMs",1284249,"viewUrl","/Search/View?dp=1&key=2792267-e57b05283d073e6b73c60e394ee37cbf&start=207&end=1284","thumbnailUrl","https://assets.pipeline.soar.com/2792267-e57b05283d073e6b73c60e394ee37cbf/thumbnail_207165.jpg","articleUrl","/articles/6104182/South-Carolina/Lawmakers-Hear-Competing-Views-on-PBMs-Role-in-Drug-Prices-and-Formularies","mediaUrl","https://secure.pipeline.soar.com/6104182-6e6e5c6716aa825c32d062162812354c/orig.mp4?Expires=1775071253&Signature=FmGMBY6ru-GtxV9kBdqdgZUiTesUL4RqgWvpctxIDFbZ-DbPD2hAf5OPP16uAgZgRPGIZDAbgwz5b~zBQUV-Ukp-x~NfJdNEDdRghliY2BMCcHJL6Am~oSfMS5~gRGd3u7~SxlzaiXE3puSbGLxHyxl1KvfT-06A3xaXih6VlS~bdsnVdiqJ5ENWrbk~Htj9cbxEz~xD1i1Sw-xCMmFFIsop0B9VOj0IzA9L-ugymUrwXZ9vn3WBHkatX4xWYQrKzL-UriB8m2TX6-J3w3Zdf6yE~PYrveEhlP5ZS~P8-oc5dpbtfmWJ~Y8lVKyR75DQXpqHiO1n4a121d~b9vAbYg__&Key-Pair-Id=KUT5TJCACFTXG","author","South Carolina Legislature","date","2025-03-18T00:00:00Z","article","CHARLESTON, S.C. — Lawmakers probing the state’s prescription‑drug system on Tuesday heard sharply differing accounts of how pharmacy benefit managers, or PBMs, affect prices, patient access and where prescriptions are filled.

The ad hoc committee convened by Rep. Heath Sessions (chair of the House medical subcommittee) heard PBM and insurer representatives argue PBMs reduce overall plan costs through negotiations, formulary design and clinical programs. Manufacturers and independent pharmacists countered that rebates, opaque fees and vertical integration have created misaligned incentives that can raise out‑of‑pocket costs, steer patients toward PBM‑owned pharmacies and squeeze local drugstores.

Why it matters: PBMs sit at multiple points in the drug supply chain — negotiating discounts with manufacturers, designing formularies and reimbursing pharmacies — giving them outsized influence over which medicines patients can access and how much consumers and plan sponsors ultimately pay. Lawmakers said they called the hearing to understand how that influence affects state purchasers (including Medicaid and the state employee plan) and South Carolina residents.

Most of the panelists outlined a complex flow of money and services. Michael Powell of the Pharmaceutical Care Management Association, which represents PBMs, said PBMs perform claims processing, manage formularies and run adherence and utilization programs for plan sponsors covering tens of millions of people. He told the committee that ‘‘plan sponsors decide how rebates are used’’ and that a small share of plan sponsors use point‑of‑sale rebate pass‑throughs to lower patients’ out‑of‑pocket costs. Powell also said generic drugs dominate dispensing and typically carry little or no rebate.

Manufacturers pushed back that much of the value negotiated as rebates does not reach patients. Charisse Richard of PhRMA pointed the committee to recent federal investigations and studies that found PBMs may exclude lower‑list‑price products from preferred formularies, impose utilization management that delays access, and steer profitable prescriptions to pharmacies they own.

Several witnesses described vertical integration — insurers and PBMs owning specialty and retail pharmacies, and sometimes provider groups — as a driver of the problems the committee is examining. The Federal Trade Commission’s ongoing PBM inquiry (cited repeatedly in testimony) reported large markups at PBM‑affiliated pharmacies and steering of high‑value prescriptions to those pharmacies.

How formularies and utilization rules work: Witnesses described formularies as plan‑level lists developed with clinical review (pharmacy & therapeutic committees) that balance clinical appropriateness and cost. PBMs and their clinical committees defended prior authorization and step therapy as tools to ensure safe, appropriate and cost‑effective use; patient groups and some providers called those tools burdensome and, in cases like cancer care, potentially harmful if they delay needed therapy.

Independent pharmacies and access: Independent pharmacy groups and the National Community Pharmacists Association told the panel that low reimbursements, retroactive adjustments and so‑called ‘‘steering’’ toward PBM‑affiliated pharmacies have forced closures in South Carolina and nationally. Witnesses said independent pharmacies sometimes are reimbursed below their acquisition cost and that state regulators have recorded permit nonrenewals. Several presenters urged reforms such as cost‑based reimbursement (for example NADAC + a dispensing fee), limits on spread pricing and banning PBM ownership of pharmacies.

340B and contract pharmacies: Johnson & Johnson told the committee that the federal 340B program — designed to deliver discounts to safety‑net providers — has grown and in some instances been used in ways that do not return discounts to patients. Witnesses described complex interactions between 340B discounts, Medicaid rebates and contract pharmacies that can reduce manufacturer net prices while exposing patients to list‑price‑based cost sharing.

Patient advocates urged protections: The American Cancer Society told the committee that copay accumulators, mid‑year formulary changes and restrictive utilization management create confusion and financial pain for cancer patients who rely on manufacturer assistance or need immediate access to prescriber‑recommended drugs.

What lawmakers will consider next: Witnesses offered a range of policy ideas — greater transparency on rebates and PBM fees, requiring rebate pass‑through to patients or plan premiums, setting minimum pharmacy reimbursement based on acquisition cost plus dispensing fee, banning spread pricing in Medicaid and curbing PBM ownership of pharmacies. Several states have enacted or proposed elements of these reforms; Kentucky and other states were cited as models for banning spread pricing and improving reimbursement transparency.

The committee did not vote on any legislation at the hearing and invited additional data and follow‑up answers from witnesses. A next meeting was scheduled by the committee for April 8.","mediaType","Video","parentTitle","House Medical, Military, Public and Municipal Affairs Committee -- 3M-LCI Pharmacy Benefit Managers Ad Hoc Committee Tuesday, March 18, 2025 9:00 am ","oneSentenceSummary","Lawmakers probing the state’s prescription‑drug system heard competing testimony on the role of pharmacy benefit managers (PBMs), with PBM and insurer witnesses saying they lower overall plan costs while manufacturers, independent pharmacists and patient advocates described rebates, opaque fees and vertical integration that can raise patient costs and reduce community pharmacy access.","taxTitle","Medical, Military, Public and Municipal Affairs, Standing, HOUSE OF REPRESENTATIVES, Committees, Legislative, South Carolina","taxId",17510,"location","South Carolina","headline","","shortSummary",{"_33":77,"_35":36,"_37":38,"_39":78,"_41":79,"_43":80,"_45":81,"_47":82,"_49":83,"_51":84,"_53":85,"_55":56,"_57":58,"_59":86,"_61":62,"_63":64,"_65":87,"_67":68,"_69":70,"_71":72,"_73":74,"_75":74},6104167,"Cancer Advocates Tell Lawmakers Prior Authorization, Accumulators Are Hurdles for Patients",890,9552500,10442500,"/Search/View?dp=1&key=2792267-e57b05283d073e6b73c60e394ee37cbf&start=9552&end=10442","https://assets.pipeline.soar.com/2792267-e57b05283d073e6b73c60e394ee37cbf/thumbnail_9552500.jpg","/articles/6104167/South-Carolina/Cancer-Advocates-Tell-Lawmakers-Prior-Authorization-Accumulators-Are-Hurdles-for-Patients","https://secure.pipeline.soar.com/6104167-0acdae999dcb4ecc8458681241708458/orig.mp4?Expires=1775071253&Signature=fujfJUgxyTbzTwG~PaxtY-LYnifB4kafTk9usWNh4RC2XLEedvFI1dVXRqu2AtM8mElQS8JF3ijx3TsGvOvhSOFBJP~z9bCZ8kGrjRnGopnZgmL8gMPAfj5jmSqO6TqRYoRt69MkrDU~OdlZlVPi26oDnFxvxCYWRmHxrAY-140m-HlJF68maWnKS5J6mXL~PRiUhsKmavPzLjkySupkNUOeaGA~kNCP1GT52E2YDjdbwSyMB2Hs25lpKi98Z6eVc4mN6l3hdQ5deFFNgeIF6rOHclJ3guaAlaPZclS3KiMMcKLQAIGl-KPd2VXV7l~O4Ma4dchFcp-iRycG6KHgvw__&Key-Pair-Id=KUT5TJCACFTXG","COLUMBIA, S.C. — Patient advocates told a legislative committee that insurer and PBM practices such as copay accumulators, prior authorization requirements and mid‑year formulary changes can create financial and administrative barriers for people with serious illnesses.

What they said: Beth Johnson of the American Cancer Society described frequent calls to the organization’s helpline from patients who face administratively complex coverage rules, mid‑year formulary changes or co‑pay accumulator adjustments that prevent manufacturer assistance from counting toward a policy’s out‑of‑pocket maximum.

Specific concerns raised:
- Copay accumulators: Patients using manufacturer copay assistance often discover that those payments do not count toward their deductible or out‑of‑pocket maximum, leaving them exposed to large bills when the assistance is applied by the PBM but not credited toward the patient’s cost‑sharing requirements.
- Prior authorization and step therapy: Advocates said these utilization‑management tools can delay critical treatments. Cancer advocates urged that utilization rules be aligned with clinical evidence and that urgent cases be fast‑tracked.
- Mid‑year formulary changes: Patients and advocates warned that changing coverage or tiers during the plan year can disrupt ongoing care and impose additional financial burdens.

Patient perspective: The American Cancer Society summarized the patient priorities as access, affordability, administrative simplicity and adequacy of coverage. Cancer patients and caregivers urged lawmakers to require greater transparency about formularies and insurer policies and to prohibit copay accumulator and copay maximizer designs that block patient assistance from reducing patient deductibles.

Committee response: Members asked advocates for concrete examples and documentation of patient harms; the committee asked for additional testimony from state health officials and legal counsel about the scope of state authority to limit accumulator programs in commercial plans.

Ending: The committee noted patient testimony as a central consideration as it weighs proposals to regulate PBM practices and protect patients from surprise or unaffordable bills.","Patient advocates described how copay accumulator programs, step therapy and mid‑year formulary changes can delay access to prescriber‑recommended therapies and leave patients responsible for higher out‑of‑pocket costs, particularly for cancer care.",{"_33":89,"_35":36,"_37":38,"_39":90,"_41":91,"_43":92,"_45":93,"_47":94,"_49":95,"_51":96,"_53":97,"_55":56,"_57":58,"_59":98,"_61":62,"_63":64,"_65":99,"_67":68,"_69":70,"_71":72,"_73":74,"_75":74},6104172,"Drugmakers and PBMs Disagree Over 340B Contracts, Discounts and Patient Benefit",194,9991189,10185495,"/Search/View?dp=1&key=2792267-e57b05283d073e6b73c60e394ee37cbf&start=9991&end=10185","https://assets.pipeline.soar.com/2792267-e57b05283d073e6b73c60e394ee37cbf/thumbnail_9991189.jpg","/articles/6104172/South-Carolina/Drugmakers-and-PBMs-Disagree-Over-340B-Contracts-Discounts-and-Patient-Benefit","https://secure.pipeline.soar.com/6104172-c5e36ed8418d154278fb0aee94f584b1/orig.mp4?Expires=1775071253&Signature=ADgP3GJs52aFnc1dEBXLa20~fnOySVmTT8JcExquVNM5xOEpahuCZDEm4cWJs8~ZS7lbnk2uVnHgJDdISYK5LkRTrWakaAQ2OVT~J3K4mpMMQoYyxgh8s7drHWhugJYU3ULZum6H4UhB3Qc0oNjVTcWvwtVQLXLqoUvewS6cxgwAYpZZUf5RByn7J1ubgtXx~dKIwjbxJC8jp0aJZUcgbXpYA2OSECGl0Tr1SZsZH7oXMmabd~oS-SlX02ryHFFnZUbTheUuoKtu0CY7ndHAH2xc2s4CX8NTwB2SflqR7n3Sd-epDTV0L-AXmWQime3mn76cAByREqZCcjKFDXqvbg__&Key-Pair-Id=KUT5TJCACFTXG","COLUMBIA, S.C. — Witnesses told a legislative committee that the federal 340B program — created to give safety‑net hospitals and clinics discounts on outpatient drugs — has expanded and become intertwined with contract pharmacies and PBM practices in ways that complicate who gets discounts and whether patients benefit.

What witnesses said: Scott White of Johnson & Johnson told the committee that manufacturers provided large discounts to 340B covered entities, and he expressed concerns that contract pharmacy arrangements and extensive use of 340B by large hospital systems and their pharmacy partners have not always routed benefits to patients. White described the program’s rapid growth and cited examples of deep discounts for covered entities and of contract pharmacies that extend the program’s reach beyond the populations originally intended.

Key mechanics and tension points: Witnesses explained that 340B discounts are statutory and typically provide deep price reductions to covered entities. Pharmaceutical manufacturers and PBMs said that when 340B discounts apply, manufacturers may not be able to claim the corresponding Medicaid rebate for the same patient; witnesses also said the Inflation Reduction Act introduced new priorities for rebate application that interact with 340B in complex ways. Manufacturers and patient advocates told the committee they are concerned that patients’ out‑of‑pocket cost sharing is often indexed to list price, not the discounted price obtained by hospitals or contract pharmacies.

Why lawmakers should care: Committee members were told that the 340B program’s expansion can have fiscal consequences for Medicaid and for manufacturer net prices, and that contract pharmacy arrangements — particularly when those contract pharmacies are affiliated with PBMs — can increase opportunities for discount capture without clear evidence of direct patient benefit.

Next steps: Members requested additional state‑level data on 340B purchases and asked federal program representatives and state agencies to clarify how program discounts interact with Medicaid rebate rules and plan cost‑sharing rules.

Ending: The committee did not reach policy decisions at the hearing; witnesses agreed to provide more documentation to help lawmakers evaluate whether state action is warranted.","Drugmakers told lawmakers that the federal 340B discount program for safety‑net providers has expanded and, in some cases, been routed through contract pharmacies in ways that do not reduce patient cost sharing. Manufacturers and PBMs gave different accounts of whether discounts reached patients.",{"_33":101,"_35":36,"_37":38,"_39":102,"_41":103,"_43":104,"_45":105,"_47":106,"_49":107,"_51":108,"_53":109,"_55":56,"_57":58,"_59":110,"_61":62,"_63":64,"_65":111,"_67":68,"_69":70,"_71":72,"_73":74,"_75":74},6104177,"Independent Pharmacies Say Low Reimbursements, Retroactive Fees Are Driving Local Closures",3799,7046190,10845676,"/Search/View?dp=1&key=2792267-e57b05283d073e6b73c60e394ee37cbf&start=7046&end=10845","https://assets.pipeline.soar.com/2792267-e57b05283d073e6b73c60e394ee37cbf/thumbnail_7046190.jpg","/articles/6104177/South-Carolina/Independent-Pharmacies-Say-Low-Reimbursements-Retroactive-Fees-Are-Driving-Local-Closures","https://secure.pipeline.soar.com/6104177-7a49fb66eb55658500b993fc75be952e/orig.mp4?Expires=1775071253&Signature=OsO1Tu86qYz3XzwpOxDilv-fPVkIMauIxhWsG8lmGoR-nUmfBB62FbPw9xA85ZBZxG5IXTvk5fa~3jiUtUpvJySCP2bEMZNHVeIS1xBC0qFqDhy7SYQzV4iJDLUdXgvVq8sisd4p-qGiz8dwUUg9B9L6AoPzV5jdXizhzkRyvU2GXLCw1oDC4BnmszWkpNEhQ8RGXI8a6MUKNr-czMkPyW8hxRtHwIbGuSq5ohTBmEWdtHvgCrLKSRzhvwppA6rvOt8Zkh57ufpnbV1Epf8C6BqN~mbB5nsKqnGWBmG~4pfA33zbF0HxJiaicFAjzR33EngUrb03a9RSaJzQv6nB4g__&Key-Pair-Id=KUT5TJCACFTXG","COLUMBIA, S.C. — Owners of independent pharmacies and their trade groups told state lawmakers that contracting and reimbursement terms set by PBMs are forcing community pharmacies to close and threatening local access to medicines.

Why it matters: Independent pharmacies are frequently the most accessible health‑care points in smaller towns and rural neighborhoods. Witnesses said repeated below‑cost reimbursement and retroactive adjustments make it impossible for many small operators to remain financially viable.

What witnesses told lawmakers: Joel (NCPA representative) and Addison Livingston (Independent Pharmacies of South Carolina) described contracts that limit pharmacy bargaining power and sometimes require buying most inventory from a single wholesaler. Livingston said two of his eight community pharmacies are no longer financially feasible and must close unless the policy environment changes. Contracting provisions and post‑payment adjustments — described in testimony as ‘‘clawbacks’’ or retroactive fees — were cited as a common reason for losses at point‑of‑sale.

Several pharmacy witnesses and trade group executives urged the committee to consider state reforms that have been adopted elsewhere: basing reimbursements on NADAC (the CMS National Average Drug Acquisition Cost) plus a professional dispensing fee or multiplier, banning spread pricing in Medicaid, restricting PBM ownership of pharmacies and strengthening state oversight and enforcement of PBM conduct.

Evidence and local impacts: Brian Clark of the South Carolina Pharmacy Association told the committee that state regulators recorded dozens of pharmacy permit nonrenewals in 2023–2024; pharmacies across South Carolina have closed or pared back hours, he said. Witnesses credited several states (Kentucky, West Virginia and Tennessee) with reporting measurable fiscal effects after adopting pharmacy reimbursement and PBM‑transparency measures.

Panel next steps: Pharmacy representatives provided the committee with requests for enforcement tools and legislative options; the committee asked for more specific documentation and local financial data to assess how state policy could change reimbursement or oversight without unintended consequences for plan sponsors and patients.

Ending: Committee members asked pharmacy groups to submit concrete, state‑specific cost and contract examples to inform drafting of bills.","Independent and community pharmacists told a legislative panel that low PBM reimbursements, retroactive adjustments and steering to PBM‑affiliated pharmacies are forcing closures and creating 'pharmacy deserts' in South Carolina communities.","actionData","errors"]

Article not found

Lawmakers Hear Competing Views on PBMs’ Role in Drug Prices and Formularies

Cancer Advocates Tell Lawmakers Prior Authorization, Accumulators Are Hurdles for Patients

Drugmakers and PBMs Disagree Over 340B Contracts, Discounts and Patient Benefit

Independent Pharmacies Say Low Reimbursements, Retroactive Fees Are Driving Local Closures