Denise Myshko is your editorial contact for the Formulary Watch. She joined Formulary Watch as editor is June 2021 from Oncology Live. Prior to that, she was managing editor of PharmaVOICE, a trade publication in the pharmaceutical industry. Email: dmyshko@mjhlifesciences.com

Denise Myshko

The politics and policies of high drug prices have been swirling around for years. But recently, attention has shifted to PBMs, which used to reside in an obscure corner of the U.S. healthcare system. At the federal level, Federal Trade Commission has launched a study of the industry and possible anticompetitive practices. A bipartisan bill has been introduced in the Senate that its sponsors say would force needed transparency and fairness on PBMs.

However, the much of the real action in PBM legislation and regulation is taking place in the statehouses in the Albanys, Topekas and Harrisburgs of the country, not in Washington. Last year alone, 12 states enacted 19 pieces of legislation that offered a variety of restrictions and requirements for PBMs, 

 to the National Academy for State Health Policy, a nonpartisan organization that tracks healthcare developments at the state level. The organization began keeping tabs on PBM legislation in 2017. The wave of new legislation includes new licensing and reporting requirements, prohibitions on spread pricing and rules that are aimed to make costs more transparent enrollees. 

“There is a greater effort and willingness to look into the conduct of PBMs and adopt legislation,” Jesse C. Dresser, an attorney with Frier Levitt, a law firm in New Jersey and New York that has filed suits against PBMs, told 

The appetite for regulating PBMs is part of an increased focus on curbing the high out-of-pocket costs that many patients are facing, observed Cynthia J. Borrelli, principal at Bressler Amery & Ross, a law firm in New York.

“We are more than 12 years past the Affordable Care Act (ACA), and the cost of healthcare has not come down, as was anticipated when the bill was put in place,” she said. “The ACA regulated carriers and the provision of care. But so much of care today is being provided not by carriers, but by other providers, including pharmacy benefit managers, and by intermediary entities. These entities have become an integral part in the delivery of the health and delivery of healthcare. It’s taken time for the government to realize that those entities need to be regulated as well.”

PBMs used to be relatively small operations that processed claims. Now they have become important parts of the large, vertically integrated healthcare companies that dominate the flow of the trillions of dollars spent on American healthcare every year, including the hundreds of billions that spent on pharmaceuticals. The three largest PBMs — CVS Caremark, Express Scripts and Optum — are part of companies that own healthcare insurance companies, physician practices, pharmacies and specialty pharmacies. They have a say-so over which drugs get covered through lists called formularies and manage distribution through their own pharmacies. CVS Caremark, Express Scripts and Optum control about 80% of the PBM market and in that context are often referred to as the big 3.

The PBMs and their trade association, Pharmaceutical Care Management Association, say they use their buying power to combat high prices set by drug manufacturers and that the rebates and discounts they receive ultimately translate into lower premiums.

But PBMs have come under a torrent of criticism from drug manufacturers, patient groups, consumer groups and some lawmakers. Their critics say their business practices are opaque, anticompetitive and simply extract profits as middlemen.

At the federal level, Sens. Chuck Grassley (R-Iowa) and Maria Cantwell (D-Wash.) introduced legislation last year that would require PBMs to report to the Federal Trade Commission how much money they make through spread pricing and pharmacy fees. The senators have reintroduced two pieces of legislation, the Pharmacy Benefit Manager Transparency Act (S. 127) and the Prescription Pricing for the People Act (S. 113).

Related: Senators Reintroduce PBM Legislation

The action on PBMs has devolved to the states partly because a 2020 U.S. Supreme Court decision, said leaders with the National Academy for State Health Policy. In 

Rutledge v Pharmaceutical Care Management Association,

 the court upheld an Arizona law that required PBMs to pay pharmacies no less than their acquisition costs for prescription drugs. The court indicated the Arizona law was not preempted by Employee Retirement Income Security Act (ERISA), a federal law that sets standards for retirement and health benefits. The decision in the case gives states the ability to regulate healthcare costs, including health plan contractors.

In 2022, 135 bills concerning PBMs were introduced in state legislatures, according to the National Academy for State Health Policy’s tracker. Most are still working their way through various committees, and some have failed to make any headway. The 19 bills that have been signed into law provide a starting point to address the undue influence that PBMs have over pharmacies and drug pricing, say the industry's critics.

Collaboration among the states can create model rules and regulations than can be adopted consistently, Chris Blackley, co-founder and chief executive officer of Prescryptive Health, said in an interview. Prescryptive is a technology company that provides mobile solutions to connect consumers, pharmacists, and employers. “One of the most positive things coming out of the state level activity and engagement is the awareness and education of the market,” commented Blackley said. “It's only recently within the last few years that people even know what a PBM is.”

Licensing and registration of PBMs is not new. All states have or will have laws providing for the registration, according to industry sources. But this new batch of licensing and registration laws provide states with authority to penalize PBMs for noncompliance, Jessin Joseph, Pharm.D., senior director, PBA Services at Capital Rx, told 

PBMs have been notorious for being difficult to work with for patients, pharmacies and states, said Joseph. “The industry is perceived in a negative light,” he added, “and in an attempt to control these practices, the licensing and registration of the PBM is something PBMs will be comfortable proceeding with as smaller or midsize PBMs often use larger PBMs as their back-end processor to meet such requirements.”

The removal of gag clauses has become another area of focus across the states. The gag clauses, which are written into pharmacy contracts with PBMs, prohibit pharmacists from telling a patient when paying by cash may be less expensive than using insurance. “Gag orders are another tactic to put the pharmacy in jeopardy when they’re not being reimbursed at a fair price,” said Blackley. “This is an important consideration that may not be immediately obvious. Pharmacies are dependent upon these major companies for as much as 25%, 30%, or 40% of their revenue. This is another way to put pressure on the pharmacies to continue to play ball and accept reimbursement rates that often don’t sustain their business.”

Dresser, the attorney with Frier Levitt, said that Michigan and New York have been trendsetters in the state-level efforts to regulate PBMs. In Michigan, several new laws were signed law year by Gov. Gretchen Whitmer, a Democrat. One required licensing of PBMs and prohibited spread pricing and pharmacist gag clauses. Another prohibits PBMs from requiring a patient to pay a copay that is higher than the selling cost of the drug dispensed or from discriminating against 340B program entities. A third law addressed pharmacists’ rights.

In New York, PBMs are now required to register with the state insurance department and pay a fee of $4,000. PBMs in New York must obtain licenses and adhere to state regulations. They will also have to report pricing discounts and rebates and are restricted from using spread pricing and prescription drug substitutions.

States that have passed PBM legislation are likely to continue to do so, Joseph said. He said lawmakers in Illinois, Massachusetts and Minnesota are moving ahead with laws targeting PBM practices. 

Last year, for example, Illinois enacted a law that requires PBMs to update maximum allowable cost (MAC) — a payment model that PBMs use to control costs — pricing information weekly. The measure also prohibits PBMs from limiting a pharmacist from sharing with patients the availability of a more affordable alternative drug. Other bills introduced in Illinois would require a PBM to disclose any value provided by a pharmaceutical manufacturer to the PBM, as well as actual amounts paid by the PBM to a pharmacy, and require PBMs to publish MAC pricing information and set up appeal procedures.

In Massachusetts, several PBM-related bills that have been referred to state committees. One would establish a committee to study maximum allowable costs. Another would require PBMs to make available all sources used to determine the maximum allowable costs for drugs. A third would require PBMs to submit transparency reports detailing rebates and administrative fees.

Minnesota, home to Prime Therapeutics, a PBM owned by Blues plans, has several pieces of legislation that been referred to committees, including one that would require PBMs to make available their formulary and other  information related to coverage.

Articles

In 2022, 12 states have enacted 19 pieces of legislation that offer a variety of restrictions and requirements for pharmacy benefit managers (PBMs).

States, not Federal Government, Are Moving to Tighten Regulation of PBMs

 to an almost 4% increase in revenue for Cigna for 2022. In total, Cigna’s adjusted revenue for 2022 was $180.62 billion compared with $174.08 billion in 2012.

“2022 was a strong year of performance and growth for our company,” David Cordani, Cigna’s chief executive officer, said in an investor call. “With our Evernorth and Cigna platforms and our durable growth framework, we are well positioned to meet the needs of our customers, clients and partners in the future.”

Evernorth, which includes a group of businesses in pharmacy benefits and benefit solutions, is the largest segment of the company’s business. It contributed $140.34 billion in revenue in 2022 compared with $131.91 billion in 2021, a growth of 5%, which is in line with the company’s target. The division includes Express Scripts PBM, Express Scripts Pharmacy, Accredo (specialty pharmacy), eviCore Healthcare (medical benefits management), CuraScript SD (specialty and medical supplies), myMatrix (workers’ comp PBM), MDLive (a virtual care platform) and Freedom Fertility.

Within Evernorth, pharmacy revenue for 2022 increased 6% from $125.81 billion to $132.99 billion. 

, company executives said the pharmacy benefits services business will contribute to future growth, and the combined pharmacy benefits services, U.S. commercial and international business have contributed 60% of the company’s revenue. Last year’s results benefitted from pricing discipline and affordability initiatives, including clinical programs, executives said.

Related: Centene Selects Express Scripts to Administer Pharmacy Benefits

And while the number of pharmacy customers in 2022 and script volume decreased because of client attrition, going forward, the company indicated that its pharmacy benefit contract starting in January 2024 with Centene will drive growth. In October 2022, Centene announced that it was switching from CVS Caremark to Express Scripts, to administer pharmacy benefits for about 20 million Centene members. Centene provides healthcare through commercial plans and government-sponsored plans, including Medicaid and Medicare, TRICARE and the Health Insurance Marketplace.

Company executives also said biosimilars will help to lower costs for the company. Express Scripts will add Amgen’s biosimilar Amjevita (adalimumab-atto) to its national preferred formulary on parity with Humira, which treats patients with arthritis and anti-inflammatory conditions. Other Humira biosimilars will be evaluated as they come to market, the company said.

 in the past that it has advocated for the adoption of biosimilars. For example, Express Scripts added Viatris’ Semglee, the first FDA-approved interchangeable biosimilar basal insulin to improve glycemic control in adults and pediatric patients with type 1 diabetes and in adults with type 2 diabetes, to its national preferred formulary beginning in 2022. The company estimates this saved more than $20 million for plan sponsors in one year.

Evernorth, Cigna’s pharmacy and benefits solutions division, contributed more than 75% of the company’s revenue last year.

Cigna’s Evernorth Division Contributed $140 million in 2022 Revenue

The presence of biosimilars in the market generally creates savings in the healthcare system, putting pressure on the prices of reference products and lowering prices overall. But when it comes to the latest biosimilar to enter the market, it’s complicated.

The recent launch of Amjevita (adalimumab-atto), Amgen’s biosimilar of AbbVie’s arthritis drug Humira has been highly anticipated. It is launching with a two-tier pricing program: the first is 5% below the current Humira price and the second is 55% below the current Humira list price. Humira’s 

 is $6,922 for a four-week supply — almost $90,000 annually.

The pricing model is meant to provide options for all payers, including commercial and government, as well as for private access to patients, said Renee Rayburg, RPh, vice president, specialty clinical consulting, Pharmaceutical Strategies Group (PSG). “The 5% model allows for PBMs to collect rebates that go to the payers and the 55% discount lowers the price and provides access for those in a high-deductible, consumer directed health plan,” she said in an interview with 

The 55% discount off Humira was surprising, Rayburg said. “Traditionally biosimilars have come to the market 10% to 30% lower than the list price of the reference product. This is probably one of the deepest discounted prices that we’ve seen.”

This would mean, she said, that Amgen is anticipating giving rebates of at least $40,000 — the difference between Humira’s list price and the 55% discount off that price. “PBMs may go the rebate route if they think the rebates could be higher,” she said. Humira has been a top cost driver in pharmacy spend for most plans. Generating competition in a category with significant financial impact for plans is promising.

There is also value for patients as well because Amgen is offering patient assistance through the Amjevita SupportPlus Co-Pay Program with $0 copays.

This may become even more important as AbbVie is now limiting its patient copay assistance for Humira if a PBM employs co-pay accumulator or maximizer programs, which do not count such assistance toward deductibles. AbbVie has a $14,000 per calendar year maximum on its assistance for Humira, but for patients with plans that have a maximizer program, the limit is now $4,000. The use of copay accumulator and maximizer programs — mechanisms used by PBMs to reduce their spending on specialty drugs — has grown from 14% of commercially-insured patients in 2019 to 33% in 2022, according to a 

But the real impact of Amjevita in terms of uptake and costs for treating patients with arthritis and inflammatory conditions may be minimal. “There’s been a lot of buzz, but I don't think one product alone is going to be enough to push the market to realize the full savings that biosimilars can offer,” Rayburg said.

The biggest impact financially will likely happen after July, when additional Humira biosimilars begin to reach the market. Being first may not help Amjevita become the dominant biosimilar for several reasons, Rayburg said. Not all of the Humira biosimilars are the same; they differ in terms of characteristics. Some reference an earlier version of Humira.

In 2018, AbbVie reformulated Humira and began offering a version that was higher concentration (which reduced volume), removed the citrate buffers (which reduced burning during injection) and uses a thinner needle. According to PSG estimates, 80% of Humira utilization is the citrate-free, high concentration formulation.

Amjevita, however, is a low-concentration version biosimilar. Amgen is developing a high-concentration version of Amjevita but that is not expected to reach the market until 2024. Rayburg said this may not be an issue with new starts, but patients currently on Humira may not want to switch.

In July 2023, Boehringer Ingelheim is expected to launch the low-concentration Cyltezo. It was approved with an interchangeable designation, which may help with uptake among physicians. Organon’s Hadlima in both a low- and high-concentration will likely have an interchangeable designation after its initial launch, and Pfizer’s application for Abrilada is under consideration for an interchangeable designation. Other Humira biosimilars expected to launch later this year include Fresenius Kabi’s Idacio, Coherus BioSciences’ Yusimry, Viatris’ Hulio, and Sandoz’ Hyrimoz but none of these are expected to have such a designation.

 of gastroenterologists, dermatologists and rheumatologists found that more than 60% would only feel comfortable prescribing an adalimumab biosimilar if it had an interchangeability designation. The survey also found that 93% of gastroenterologists said they are at least somewhat comfortable prescribing adalimumab biosimilars. Dermatologists also said they were also concerned about payers and PBM coverage.

Related: First Humira Biosimilar is Now Available

PBM coverage for Amjevita is not likely to have an impact for current Humira patients because there will likely not be much incentive for physicians to switch their patients, Rayburg said. Several PBMs — including Optum Rx and Express Scripts — have already indicated they will include some of these biosimilars as preferred products alongside Humira. Optum Rx has said they will include Amjevita and two other biosimilars on the Select and Premium formularies. An Optum Rx spokesperson said that beginning February 1, clients can include both Amjevita list price options on the commercial formulary.

A CVS Caremark spokesperson indicated that Humira will remain preferred and Amjevita will be placed on a non-preferred brand tier. Beginning Feb. 1, it will cover Amjevita on its commercial template formularies.


The real impact may not likely be seen until after July when additional biosimilars referencing Humira are launched.


 Will the Biosimilar Amjevita Lower Costs?

 Jesduvroq (daprodustat) for the once-a-day treatment of anemia due to chronic kidney disease (CKD) in adults on dialysis. Chronic kidney disease is characterized by progressive loss of kidney function and is a risk factor for cardiovascular disease. Anemia is a frequent complication of CKD and affects about 700 million patients worldwide, with an estimated one in seven patients also developing anemia. In the United States, about 810,000 patients have end-stage renal disease, of which 558,000 patients receive dialysis.

Developed by GSK, Jesduvroq is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI). It works to increase production of erythropoietin (EPO), which stimulates production of hemoglobin and red blood cells.

A spokesperson for GSK said they are working to make Jesduvroq available as soon as possible. A wholesale acquisition cost has not yet been set for Jesduvroq. Because 87% of dialysis patients are on Medicare, GSK is in the process of submitting the required documentation with Centers for Medicare & Medicaid Services (CMS) to help ensure timely reimbursement and patient access to Jesduvroq. This is expected in the fourth quarter 2023/first quarter 2024 time frame.

“Anemia of CKD can be a debilitating condition that is challenging to manage. This news means that patients on dialysis who are living with anemia of CKD now have another treatment option to help manage their anemia,” LaVarne Burton, president and chief executive officer of the American Kidney Fund, said in a press release.

The approval is based on the results of the ASCEND-D trial, which were 

 in December 2021. The study compared Jesduvroq with Aranesp (darbepoetin alfa), and Jesduvroq demonstrated noninferiority based on mean change in hemoglobin. The label includes a boxed warning about the increased risk of death, myocardial infarction, stroke, venous thromboembolism, and thrombosis of vascular access. Jesduvroq increases the risk of thrombotic vascular events, including major adverse cardiovascular events (MACE).

In October 2022, the Cardiovascular and Renal Drugs Advisory Committee (CRDAC) 

 13 to 3 to support the use of Jesduvroq for adult dialysis patients with anemia of chronic kidney disease. But the committee did not support its use in non-dialysis patients. The ASCEND-ND trial of non-dialysis patients found that hazard ratio of time to first the major adverse cardiovascular event was 1.03. (A hazard ratio above 1 indicates increased risk of harm.) Committee members indicated they were uncertain about the possibility of increased cardiovascular risks in the non-dialysis patient population.

Jesduvroq is currently approved in Japan as Duvroq for patients with renal anemia. In 

, the European Medicines Agency validated the marketing authorization application (MAA) for daprodustat, which is currently under review.

Daprodustat, now with the brand name of Jesduvroq, is a new oral therapy but it carries a boxed warning about the risk of cardiovascular events.

FDA Approves Novel Therapy for CKD-Related Anemia

 the first of the highly anticipated biosimilars of AbbVie’s blockbuster arthritis/anti-inflammatory drug Humira (adalimumab). Amgen is making Amjevita (adalimumab-atto) available with two pricing options. The first is a 5% below the current Humira price of $6,922 for a four-week supply. The second would be 55% below the current Humira list price.

“Biosimilars are extensively studied, FDA-approved treatments that have the potential to reduce costs to the healthcare system,” said Steven Taylor, president and chief executive officer at the Arthritis Foundation, said in a press release. “Amjevita provides another treatment option for patients and their doctors.”

While Amgen wouldn’t provide specifics about the two pricing programs, it’s likely that the program with the 5% discount off Humira will provide higher rebates. “For some entities in the system, the financial considerations mean a higher list price may allow for broader access for patients,” an Amgen spokesperson told 

. “Each entity can choose the list price that works best for the patients they serve.”

The Amgen spokesperson said the company is pursuing broad coverage across commercial, Medicare and Medicaid plans, and eligible commercially insured patients may pay as little as $0 per month with the Amjevita SupportPlus Co-Pay Program.

Humira is a widely prescribed drug in the United States, with sales of more than $17 billion in 2021 in the Unites States alone. Eight biosimilars referencing Humira have been approved. The most recent is Fresenius Kabi’s Idacio, which was approved in December 2022. Amgen’s Amjevita is the first to be launched and the others will follow in second half of the year, including: Organon’s Hadlima, Boehringer Ingelheim’s Cyltezo, Coherus BioSciences’ Yusimry, Viatris’ Hulio, Sandoz’ Hyrimoz, and Pfizer’s Abrilada.

Several PBMs — including Optum Rx, Express Scripts and Prime Therapeutics — have already indicated they will include some of these biosimilars as preferred products alongside Humira. 

A spokesperson from Prime, however, said it is not adding Amjevita at this time and has no further updates. A CVS Caremark spokesperson indicated that Humira will remain preferred and Amjevita will be placed on a non-preferred brand tier. Beginning Feb. 1, it will cover Amjevita on its commercial template formularies. 

“We believe this approach provides coverage for members who choose to access the biosimilar, but provides flexibility to continue to evolve our formulary strategy and minimize member disruption as additional biosimilars launch beginning in July,” the spokesperson told 

. “We will continue to use our evaluation framework to thoughtfully evaluate both Humira and Amjevita against each new competitor and we will keep our clients informed every step of the way. Over the next two years, we expect our clients to benefit from significant savings in the autoimmune categories where biosimilar competition exists.”

Express Scripts has indicated that it will add biosimilars to its largest formularies as preferred products to treat inflammatory conditions, but the PBM hasn’t decided yet which of the Humira biosimilars it will add. The company 

 in the past that it has advocated for the adoption of biosimilars. For example, Express Scripts added Viatris’ Semglee, the first FDA-approved interchangeable biosimilar basal insulin to improve glycemic control in adults and pediatric patients with type 1 diabetes and in adults with type 2 diabetes, to its national preferred formulary beginning in 2022. The company estimates this saved more than $20 million for plan sponsors in one year.

Optum Rx has said they will include Amjevita and two other biosimilars on the Select and Premium formularies. An Optum Rx spokesperson said that  beginning February 1, clients can include both Amjevita list price options on the commercial formulary. "This approach delivers choice to our clients, consumers and providers while encouraging increased competition, which results in lower costs in this important and high-spend drug class," the spokesperson said. In a statement, Optum Rx indicated they expect to see double-digit client net cost improvement in 2023 vs. 2022 alone.

Prime has said it will include some of the biosimilars on its preferred list of drugs, the NetResults formulary, but has not made a decision about which ones.

Related:OIG: Biosimilars Can Save Money for Medicare and Beneficiaries

A spokesperson for the Centers for Medicare and Medicare Services said that Amjevita and the additional Humira biosimilars will be considered Medicare Part D drugs if used for a medically accepted indication and may be included on a plan’s formulary. But since Amjevita just launched, CMS will have a better sense of Part D formulary coverage after the March 2023 formulary submission window.

Last year, the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services in reported indicated that increased use of biosimilars could reduce Medicare Part D spending by 18% and beneficiaries’ out-of-pocket costs by 12%.

This story has been updated to include additional information from Optum Rx and from CMS.

Some PBMs will offer Amgen’s Amjevita biosimilar as a preferred product alongside Humira, but CVS Caremark said Humira will remain preferred and Amjevita will be placed on a non-preferred brand tier.

First Humira Biosimilar is Now Available

Sens. Chuck Grassley (R-Iowa), ranking member of the Judiciary Committee, and Maria Cantwell (D-Wash.), chair of the Committee on Commerce, Science and Transportation, have 

 two legislative bills that aim to bring transparency to the PBM industry.

“Year after year, the price of prescription drugs has skyrocketed, far outpacing inflation and leaving patients and taxpayers footing the increasingly outrageous bill. I’ve worked to battle price increases on many fronts, but we can’t truly restore sanity to drug prices without addressing pharmacy benefit managers. PBMs, the industry middlemen, operate in the shadows and drive up prices for consumers. These bills bring about greater transparency to their industry and prevent unfair or anticompetitive practices that harm consumers,” Grassley said in a press release.

Related: Bipartisan Bill Aims to Require Transparency Among PBMs

The senators had introduced the Pharmacy Benefit Manager Transparency Act (S. 127) last year with bipartisan support. This legislation would ban deceptive pricing and prohibit arbitrary claw backs of payments made to pharmacies. The bill would also eliminate “spread pricing” in which a PBM charges a health insurance plan more to process a prescription than it reimburses the pharmacy.

This bill would also require PBMs to file an annual report with the FTC, disclosing how many it charges health plans and pharmacies for a drug, the fees that PBMs charge pharmacies, and the difference between affiliated and nonaffiliated pharmacies pay for drugs, according to a 

Both senators also sponsored the Prescription Pricing for the People Act (S. 113), which requires the Federal Trade commission (FTC) to examine the effects of consolidation in the PBM industry on pricing. The senators want to know whether PBMs steer patients to pharmacies they own, use formulary designs to favor drugs with rebates over lower cost options, or charge certain payers a higher price. The bill instructs the FTC to provide policy recommendations to Congress to improve competition and protect consumers, according to a 

Several organizations — including the National Community Pharmacists Association, the Autoimmune Association, the Community Oncology Alliance — support the bills. “For years now, PBM tactics have led to increased costs and delayed access to care for consumers. They have also made it harder for small business pharmacies to keep their doors open. That weakens the entire health care system, because community pharmacies provide essential services to millions of Americans, especially underserved population,” Anne Cassity, senior vice president of government affairs at the national Community Pharmacists Association.

Grassley has been a critic of the PBM industry, and since 2018 has been working to have the FTC investigate the PBMs and their pricing tactics.

Related: FTC Launches Investigation of PBMs

Last year, the FTC launched an investigation into PBM business practices of the six largest PBMs, including the impact of rebates on formulary design, the costs of prescription drugs to patients, and methods to determine pharmacy reimbursement. At the same time, the FTC issued an enforcement policy stating that rebates and fees that exclude competitors offering lower-cost drug alternatives can violate competition and consumer protection laws.

The proposed legislation, sponsored by Sens. Chuck Grassley and Maria Cantwell, aims to increase transparency of PBM business practices. 