BILL NUMBER: S5939

SPONSOR: SKOUFIS
 
TITLE OF BILL:

An act to amend the public health law and the insurance law, in relation
to payments by pharmacy benefit managers to participating pharmacies

 
PURPOSE OF THE BILL:

The Pharmacy Transparency Act (PTA) seeks to simplify and change the
methodology for pharmacy reimbursement for commercial health plans to a
Cost-Plus model that is more transparent for patients, payors, and phar-
macies while saving costs through the process.

 
SUMMARY OF SPECIFIC PROVISIONS:

Section 1: Amends subdivision 1 of section 280-a of the public health
law by adding paragraphs (j) and (k). To define the Pharmacy Acquisition
Cost Rate as the cost a participating pharmacy pays to acquire drugs,
including generic, brand-name, biologics, and those produced through
genetic or biopharmaceutical processes, based on pharmacy cost invoices.
              

It also defines the National Average Drug Acquisition Cost as the month-
ly survey conducted by the Centers for Medicare and Medicaid Services
(CMS) to determine the average acquisition cost of Medicaid-covered
outpatient drugs.

Section 2: Amends subdivision 3 of section 280-a of the public health
law to add a paragraph (b). To prohibit pharmacy benefit managers from
substituting or altering prescription drugs without prescriber approval
or legal authorization. The superintendent and commissioner may issue
regulations on when substitutions are permitted.  Additionally, pharmacy
benefit managers must reimburse participating pharmacies at least the
National Average Drug Acquisition Cost (NADAC) rate or the Pharmacy
Acquisition Cost Rate, whichever is higher, plus a professional dispens-
ing fee equal to or greater than that paid under the state medical
assistance program. For medications requiring specialized handling,
distribution, administration, patient education, care coordination,
monitoring, special packaging, or shipping, pharmacies must receive an
additional dispensing fee to ensure they are not reimbursed below their
acquisition and dispensing costs.

Section 3: Amends the opening paragraph of subdivision 4 of section
280-a of the public health law. To require pharmacy benefit managers to
establish a reasonable process for pharmacies or their contracting
agents to appeal, investigate, and resolve disputes over drug pricing
for multi-source generics, brand-name drugs, biologics, and drugs
produced through genetic or biopharmaceutical processes. This appeals
process must be incorporated into existing appeals procedures under this
section.

Section 4: Amends section 2911 of the insurance law to add a new
subsection (d) to ensure that pharmacy benefit managers reimburse phar-
macies fairly by covering the actual cost of acquiring and dispensing
medications. It mandates payment at either the National Average Drug
Acquisition Cost (NADAC) rate or the Pharmacy Acquisition Cost Rate,
whichever is higher, along with a professional dispensing fee. Addi-
tional compensation is required for drugs needing special handling,

administration, or monitoring. The amendment also establishes a stand-
ardized appeals process for pharmacies to dispute pricing issues.

Section 5: Sets Effective Date.

 
JUSTIFICATION:

The Pharmacy Transparency Act (PTA) is part of an ongoing effort to
reduce prescription drug costs for patients, enhance pharmacy access in
underserved areas, and increase transparency regarding the costs that
plan sponsors and employers are paying for prescription drugs, ultimate-
ly leading to significant cost savings. This initiative adopts the Cost-
Plus reimbursement methodology, which New York State Medicaid imple-
mented in 2023. This approach has resulted in consistent patient
coverage, enhanced rebate revenues, and a stabilization of prescription
drug costs.

Pharmacy Benefit Managers (PBMs) play a crucial role in delivering phar-
macy services, working on behalf of plan sponsors or employers to manage
pharmacy benefits. Historically, PBMs were primarily responsible for
processing claims. However, over the past two decades, they have oper-
ated in a largely opaque environment, negotiating rebates with pharma-
ceutical companies intending to reduce prescription costs. Unfortunate-
ly, the savings from these rebates have not been passed on to patients
or those paying for pharmacy benefits. Year after year, insurance premi-
ums for commercial health plans have risen by 8-1315, with pharmaceu-
tical companies being blamed as the primary driver of these increases.
This is despite the fact that, in 2024, the list prices for average
brand-name drugs grew by only 2.3%. After adjusting for overall
inflation, the net prices of brand-name drugs have actually dropped for
seven consecutive years. This discrepancy is largely attributed to the
"rebate pumping" phenomenon, where PBMs negotiate higher rebates by
increasing drug prices, creating a gross-to-net pricing bubble.

Given that PBMs are licensed and monitored by the New York State Depart-
ment of Financial Services (DFS), the time has come to bring greater
transparency to the actual cost of prescription drugs. By adopting the
National Average Drug Acquisition Cost (NADAC) as a national standard
for determining pharmacy reimbursement, we can more accurately reflect
the costs incurred by pharmacies to acquire medications. The Cost-Plus
methodology moves away from the previously used Average Wholesale Price
(AWP) model, which was often inflated, as well as the Wholesaler Acqui-
sition Cost (WAC) and Maximum Acquisition Cost (MAC) pricing methodol-
ogies, which were inconsistent and did not accurately capture pharmaceu-
tical costs.  NADAC, a nationally recognized benchmark, is so widely
accepted that the three major PBMs, which control over 80t of all phar-
macy claims, have announced plans to adopt the Cost-Plus model for
commercial plans by 2026.

The PTA is also critical in light of years of bipartisan findings by the
U.S. Congress and the Federal Trade Commission (FTC). It highlights how
PBMs have established reimbursement practices that favor their pharma-
cies over independent pharmacies and steer high-cost specialty drugs to
their operations. Despite denials from the major PBMs, the FTC has been
highly critical of these practices, and the 119th Congress is actively
exploring measures to increase scrutiny, transparency, and accountabil-
ity in the management of public funds.

The passage of the PTA will provide a clear, standardized framework for
pharmaceutical reimbursement that benefits both patients and payors.
This legislation will ensure stable reimbursement to pharmacies regard-
less of ownership or location. It represents a significant step toward
creating a more transparent, equitable, and sustainable pharmaceutical
pricing system.

 
LEGISLATIVE HISTORY:

Senate

2023: N/A

2024: S9570, Referred to Health

Assembly

2023: N/A

2024: A10327, Referred to Health

 
FISCAL IMPLICATIONS:

None to the state

 
EFFECTIVE DATE:
This act shall take effect immediately.