Shapiro Administration Launches New Online Portal for Pharmacies, Streamlining Complaint Process to Challenge Insurance Company and PBM Decisions | Insurance Department |[...]

Harrisburg, PA - The Pennsylvania Insurance Department (PID) today launched a user-friendly online portal especially designed for pharmacists to file complaints and challenge an insurer's or PBM's classification of a drug as a specialty drug, which can impact prescription availability and cost of medications for consumers.

In July 2024, Governor Josh Shapiro signed into law the Pharmacy Benefit Reform Act (Act 77 of 2024), a state law that expanded PID's authority over PBMs to increase fairness and transparency of prescription drug coverage in fully-insured plans. As part of this historic reform, Act 77:

• Requires transparency of PBM operations and pricing;
• Allows PID to analyze PBM practices that may result in increased healthcare costs for consumers; and
• Prohibits any pharmacy from charging a price that is more than the consumer would pay if they walked in off the street and paid in cash.

"Pennsylvanians deserve a prescription drug system that works for them," said Pennsylvania Insurance Commissioner Michael Humphreys. "We built this updated portal to make sure that the complaint and specialty drug appeal process is clearer, faster, and easier for pharmacies to use. When pharmacies can quickly file a complaint or challenge a specialty drug designation, PID can work efficiently to protect Pennsylvanians from predatory actions of PBMs.

The new portal creates a single, streamlined submission form that collects all required information and allows pharmacies to file complaints related to clawbacks, steering, rebates and reimbursement. The portal improves the speed of submissions, while reducing the potential for errors or missing details that can delay a review.

Additionally, a pharmacy that believes a drug has been incorrectly classified as a Specialty Drug can request a review of specialty drug designation through the new portal. PID will review the request, identify if it is eligible, and then decide whether the classification should be changed.

"As an officer of the Pennsylvania Pharmacist Association, I appreciated the opportunity to work with PID and several pharmacists across the Commonwealth to help develop the Pharmacy Online Portal," said John DeJames, Officer of the Pennsylvania Pharmacist Association. "Pharmacists will now have a mechanism to report complaints to the PID, as they relate to Act 77. This will give pharmacies a repository to file inquiries concerning: specialty drug referral, clawbacks, patient steering, network adequacy, reimbursements, and rebates."

PBMs are the "middlemen" of the pharmaceutical supply chain. They typically negotiate the price of prescription drugs between health insurance companies and drug manufacturers, set compensation formulas for pharmacy payments, and determine patient co-payments. Despite their influence and outsized role in our healthcare system, many Pennsylvanians are unaware of the existence of PBMs.

Although the portal is designed for pharmacies to submit complaints, Pennsylvanians will also benefit from a system that is more transparent and responsive to pharmacies' concerns. Consumers can continue to submit their complaints by visiting pa.gov/consumer or calling 1-866-PA-COMPLAINT (1-866-722-6675). 

PBMs and pharmacies looking for more information about Act 77 can visit PID's Pharmacy Benefit Reform Act page.

To learn more about insurance, visit  PID's website. Follow PID on Facebook, Instagram, X or LinkedIn.