Increased Transparency for Drug Coverage Decisions in Medicare Part D.
This Act enhances oversight of Pharmacy Benefit Managers (PBMs) within Medicare Part D. It requires PBMs and plan sponsors to report when internal entities override the initial drug coverage recommendations made by independent expert committees. The goal is to ensure formulary decisions are transparent and based on patient needs rather than potential conflicts of interest.
Key points
PBMs must disclose when they alter or reverse initial recommendations made by Pharmacy and Therapeutic Committees regarding drug coverage lists (formularies).
Plan sponsors must provide a justification for every decision that overrides the expert committee's initial drug recommendation.
The law aims to increase transparency in drug access decisions for Medicare beneficiaries starting in 2026.
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