The pharmacists are hoping at least one of two similar bills — Senate Bill 841 and House Bill 2632 — survives this week’s committee deadline.

Pharmacy benefit managers — known as PBMs — and their powerful allies are doing all they can to stop the measures.

The bills would make PBM networks accept any pharmacy willing to meet their price and service requirements and to forego certain business practices others say have contributed to spiraling prescription drug prices.

The bills would also outlaw “gag rules” that prevent pharmacists from telling patients about cheaper alternatives to their prescribed drugs, and set in statute “access” minimums — that is, networks would have to have pharmacies within a reasonable distance of most policyholders.

The pharmacists say PBMs are running them out of business, particularly in rural areas, and costing patients millions in prescription costs.

PBMs say the opposite is true, that they save insurance providers — that is, employers — millions, and that the legislation sought by the pharmacists will cost state government and businesses millions more.

“These bills will negatively impact pharmacy bills,” said Fred Morgan, the chief executive officer of the Oklahoma State Chamber, which is among those lobbying against SB 841 and HB 2632. “They’re going to increase the costs of drugs.”

Hogwash, says state Rep. T.J. Marti, R-Broken Arrow, and one of two active pharmacists in the Legislature.

“We need some parity in prescription drugs,” said Marti. “Anybody who can’t see that is looking out for somebody else.”

The House and Senate bills passed from their respective chambers without dissent, but must get through committee meetings in the opposite chambers this week to remain active. HB 2632, by Rep. Jon Echols, R-Oklahoma City, has 31 Senate and 21 House co-authors.

But a heavy-hitting lineup has come out in opposition. It includes such large employers as Boeing, Devon Energy, Continental Resources and the Muscogee Creek Nation. Several insurance companies and associations are against the bills, and so is Tulsa’s Fraternal Order of Police.

The debate over PBMs and their business practices is a national one, and it cuts across party lines. Congress is looking into them and so are several states.

PBMs manage just about all prescription plans, whether through commercial insurance, self-insurance or government plans such as Medicare Part D. In theory, they negotiate lower prices for their clients — the insurance providers, not the patients — while handling all administrative functions.

PBMs began as true third-party administrators that mostly processed claims and handled paperwork.

With the advent of managed care, however, they assumed more active roles in putting together provider networks and negotiating drug prices.

But as PBMs changed, their relationships to insurers, pharmacies and even drug companies became more complex. Marti says

the Affordable Care Act’s attempt to cap health insurers’ profit margins at 15 percent caused them to look to PBMs as a way to boost their bottom lines.

“PBMs have no such restrictions,” Marti said.

“The insurance companies said we can funnel our profits through PBMs.”

The three largest PBMs — Express Scripts, CVS Caremark and OptumRX — own or are owned by a combination of pharmacy chains and insurance companies.

Express Scripts, for instance, was recently acquired by the insurance company Cigna. CVS Caremark is under the same corporate banner as CVS pharmacies and Aetna insurance. OptumRX is owned by UnitedHealth Group, the largest health care company in the world.

According to a 2018 Health Affairs article, those three account for 85 percent of the prescriptions in the United States.

Marti, who operates four Tulsa-area pharmacies, said pharmacists like him have little leverage in dealing with the large PBMs and no recourse if they’re excluded from a network.

In some cases, pharmacists complain because they belong to networks they say don’t adequately reimburse them for the cost of drugs, or in some cases don’t allow them to advise patients of lower-cost alternatives to their prescriptions.

In other cases, pharmacists say they’re shut out of networks because they are independents.

“The little guys are trying to fight to stay alive,” Marti said.

Morgan and at least some employers see things differently. The proposed legislation, he said, is “trying to create a profit for someone and use the state government to do it. We don’t agree with that.”

He said the state chamber opposes all “any willing provider” legislation — that is, the requirement that anyone willing to meet the requirements of a provider network must be accepted by that network.

Morgan said PBMs are able to negotiate lower rates by promising higher volume to pharmacies. Expanding networks, he said, lowers volume to individual establishments.

Morgan said the state chamber is also concerned because the proposed legislation would apply to self-insured health and workers compensation plans.

Asked what he would tell independent pharmacists who say they’re being squeezed out, Morgan said, “That’s not my job, but the industry is evolving and businesses have to adjust to that.”

Still, the complaints about PBMs do not appear completely unfounded. A pending class action lawsuit against Mylan NV alleges it conspired with PBMs to dominate the epinephrine injector market by artificially raising the price of its EpiPens, then reimbursing the PBMs through rebates.

According to the suit,

the higher cost of the EpiPens was passed along to insurers, insurance providers and consumers, while the PBMs kept the rebates.

Critics, including Marti, say that as PBMs decline in number while becoming more entwined with insurers and pharmacies their financial incentives shift from keeping costs to clients and consumers down to keeping them up.

But, Morgan said, employers would not continue using PBMs if they weren’t cost effective. He noted that the State Chamber helped negotiate a truce between the two parties several years ago that brought in the state insurance department to arbitrate disagreements between PBMs and pharmacists.

The cease fire is coming apart, he said, because, “The insurance commissioner maybe needs more staff to handle the numerous challenges from the pharmacists. I think it’s not worked as well as the pharmacists had hoped.”