New York Pharmacy Benefits Bureau Issues Request for Data on Pharmacy Reimbursement Practices by PBMs in New York

Since being established in May 2022, New York’s Pharmacy Benefits Bureau (“Bureau”) has requested input from the public on several occasions regarding New York’s laws governing Pharmacy Benefit Managers (PBMs). The Bureau’s most recent request seeks additional input from the Public on PBMs in New York related to PBMs’ reimbursement practices. The Bureau, as an Administrative Agency, is authorized to enact rules and regulations that could potentially benefit independent pharmacy providers, plan sponsors, and other stakeholders throughout New York (and beyond).

In its most recent request, the Bureau seeks data on pricing models and pharmacy reimbursement practices by PBMs in New York. In making this request, the Bureau noted that it is empowered to address questionable business practices employed by PBMs, including anti-competitive practices, unfair claims practices, and other issues of concern regarding PBMs reimbursement practices and other fees assessed by PBMs against pharmacies and other providers in New York.

In this Request, the Bureau seeks documented evidence (including written datasets, cost analyses, comparative data, studies, and documented facts) from any interested parties related to pricing models and pharmacy reimbursement practices by PBMs in New York State, including, but not limited to:

• Pricing methods using various cost measures (i.e., Average Wholesale Price (AWP), Maximum Allowable Cost (MAC), Wholesale Acquisition Cost (WAC), and National Average Drug Acquisition Cost (NADAC));
• Transparency within pricing methods or pharmacy reimbursement practices;
• Reimbursements or other payments such as dispensing fees paid to pharmacies;
• Retroactive clawbacks or other retroactive payments from pharmacies to PBMs in relation to pharmacy claims;
• The means of delivery of pharmacy reimbursements and any other related documentation (such as documents itemized by claims) to pharmacies;
• Time of pharmacy reimbursements delivered to pharmacies in relation to a claim (i.e., comparisons on the time of reimbursement delivery amongst different PBMs); or
• Any relevant NDC-specific data from pharmacies (including cost measures, pharmacy’s actual acquisition costs, service fees, dispensing fees, total claims, reimbursements amongst different PBMs or pricing models, etc.) regarding the financial interactions of specific drugs of interest (including drugs with highest/lowest claim costs, dispensing volume, dispensing fees, reimbursement rates, and other relevant measures).

The Bureau encourages any interested parties to submit any comments by October 31, 2022. If you would like to work with Frier Levitt to participate in this process, please contact us as soon as possible as there is limited time to prepare and submit a comment to the Bureau. 

This request presents another important opportunity to be a leader on important issues, offer unique insight and perspective on PBMs with the Bureau and participate in New York’s rulemaking process.

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Frier Levitt represents thousands of pharmacies across the United States along with other industry stakeholders, and emphasizes PBM issues (including in New York). We have successfully taken on some of the most troubling and complex PBM tactics including improper PBM reimbursement practices, PBM network access issues, DIR fees and other PBM reimbursement issues. Our attorneys have extensive knowledge of all aspects of PBMs as they relate to their relationships with Payors and Pharmacies. Contact us to speak with an attorney about how Payors and Pharmacies can leverage the various laws and protections afforded to such entities, including the important PBM laws in New York, and also participate in this important opportunity.