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Supreme Court of the United States Delays Oral Arguments Currently Scheduled for April Session

The US Supreme Court has postponed its April calendar, including Rutledge v. PCMA, the landmark case on whether states can adopt meaningful regulations on PBMs. The Court will reschedule the case for a later date. Updates will be made available as they surface.  In the meantime, click this link to read the Court’s announcement.

Pharmacy DIR Fees

In the spring of 2019, the Trump administration failed to adopt a proposed rule containing a number of Part D policy changes, including critical reform of Part D pharmacy price concessions, also known as direct and indirect remuneration (or DIR fees).

Under the current system, pharmacy benefit managers claw back fees from pharmacies well after a transaction. Those fees, called direct and indirect remuneration (DIR), are unpredictable and seemingly unconnected to a pharmacy's performance related to adherence and other standards. The fees also disadvantage patients, who are assessed a higher cost-share against their Part D deductible rather than the retroactive, lower adjusted price. The result is to push patients more quickly into the so-called Part D donut hole, at which point the patient is responsible for a considerably larger portion of their prescription drug costs.

National efforts are still underway to continue to work with leaders in the Senate and House on legislation to reform the system. The Senate Finance Committee is currently working on drug pricing legislation, to include a requirement that all price concessions from pharmacies be accounted for in the "negotiated" price at the point of sale. The only price adjustments that could be made retroactively would be additional incentive payments made to the pharmacy by the plan/PBM. This would give pharmacy owners greater clarity about their reimbursement under Medicare Part D at the time a medication is dispensed.

Prescription Drug Price Transparency Act – H.R. 1035

Generic prescription drugs account for over 80 percent of medications dispensed by community pharmacies, yet there is no transparency into how they are priced in federal health programs by PBMs.  Through hidden maximum allowable cost (MAC) lists, PBMs can overcharge federal health programs while paying much lower reimbursement rates to community pharmacies.

The Prescription Drug Price Transparency Act (H.R. 1035) introduced by Reps. Doug Collins R-Ga.) and David Loebsack (D-Iowa) seeks to bring clarity to generic drug payments in Medicare Part D and the Federal Employee Health Benefits (FEHB) program. Congress should enact H.R. 1035 to:

  • Ensure effective oversight of taxpayer dollars in federal health programs. Would enhance program integrity and establish MAC as a drug pricing standard.
  • Encourage utilization of cost-saving generic drugs whenever appropriate. Would support fair reimbursement and incentivize community pharmacists to actively promote generic drugs to cut costs. Pharmacists' generic recommendations are accepted 95 percent of the time by physicians.3
  • Support access to independent community pharmacies. Would give community pharmacies insight into the basis for MAC reimbursement rates, certainty that they are updated to reflect real-world prices (at least every seven days), and an effective appeals process to contest below-cost payments.
  • Protect patient choice of pharmacy. Would prohibit PBM corporations from requiring or incentivizing patients use the mail order and specialty pharmacies they own, which creates a conflict of interest, or exploiting private patient data for those purposes.

Ensuring Seniors Access to Local Pharmacies Act – H.R. 4946

Medicare beneficiary access to prescription drugs is impeded by mandates from PBMs that dictate which pharmacy to use based on exclusionary “preferred pharmacy” arrangements between PBMs and, often, Big Box or mail order pharmacies.

Independent community pharmacies are not allowed to participate in some of these arrangements, even if they offer to accept the Part D plan’s same contract terms and conditions. This can raise access issues for patients in underserved and rural areas in which independent community pharmacies are predominantly located, which means seniors in these communities often face either higher copays or trips of 20 miles or more to a "preferred" pharmacy. NCPA One-Pager

Medicare

Community pharmacies provide cost-saving medication and pharmacy services to millions of Medicare Part B and D patients. Congress and the Centers for Medicare and Medicaid Services (CMS) are making changes to the program all the time.

As Medicare beneficiaries review their 2020 Medicare Part D choices, you are sure to get an abundance of questions, so be prepared. The Open Election Period, or OEP, for beneficiaries runs October 15- December 7. NCPA has produced resources with specific information for the 2020 year to help you in assisting your patients.  Below is a list important changes that community pharmacists should know.

Resources

2020 Medicare Part D Pharmacist Quick Reference Guide

2020 Medicare Part D Fact Sheet

Bagstuffer for Patients and Caregivers about Annual Election Period

Ensuring Seniors Access to Local Pharmacies Act – H.R. 4946

Medicare beneficiary access to prescription drugs is impeded by mandates from PBMs that dictate which pharmacy to use based on exclusionary “preferred pharmacy” arrangements between PBMs and, often, Big Box or mail order pharmacies.

Independent community pharmacies are not allowed to participate in some of these arrangements, even if they offer to accept the Part D plan’s same contract terms and conditions. This can raise access issues for patients in underserved and rural areas in which independent community pharmacies are predominantly located, which means seniors in these communities often face either higher copays or trips of 20 miles or more to a "preferred" pharmacy.

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