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E&C approves PBM, Medicare coverage bills

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Dec 6, 2023
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Illustration: Maura Losch/Axios

The House Energy and Commerce Committee teed up a series of health bills for floor votes during a marathon markup on Wednesday afternoon.

Driving the news: The bills reflect a bipartisan consensus on reforming PBMs and Medicare cost-sharing, along with physician fee schedule and alternative payment models reform.

  • Among the measures reported out of committee in a series of unanimous roll call votes were:

1. The Protecting Patients Against PBM Abuses Act which would delink PBM compensation from the price of the drug in the Medicare program and instead use a flat fee.

  • But co-sponsors Buddy Carter and Lisa Blunt Rochester expressed frustration at not being able to address "spread pricing" — a practice in which PBMs charge a different amount to the health plan sponsor than they reimburse the pharmacy.
  • "Earlier this year this committee banned spread pricing in Medicaid. It only makes sense that we would take this step in Medicare, too ... as we reconcile PBM legislation, in the hopes of bringing it to the House floor," said E&C Chair Cathy McMorris Rodgers.
  • She committed to addressing spread pricing in Medicare at a later date.

2. H.R. 4881, a measure which would limit patients' cost-sharing to the net price for Medicare Part D drugs starting in 2027. A similar provision was included in the Ways and Means version of a health care transparency package, but was taken out of the final version of the bill.

  • It's notable then that Energy and Commerce unanimously approved the bill.
  • "While I am supportive of the goal of H.R. 4881 to ensure that a beneficiary's cost sharing at the pharmacy counter is no more than the price paid for the drug by their insurance plan ... the policy as drafted will continue to need to be refined," said Ranking Member Frank Pallone, referring to suggested technical changes.
  • McMorris Rodgers committed to working with Pallone on changes.

3. The MERIT Act which would require CMS to review drugs individually, not as a class, when making Medicare coverage decisions. The bill was drafted in response to the agency's decision last year to allow for limited coverage of the controversial Alzheimer's drug Aduhelm.

4. The Expanding Seniors' Access to Lower Cost Medicines Act of 2023 would allow formularies to make midyear changes to cover newly available biosimilars.

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