This past week, the much touted Walgreens-Prime Therapeutics Strategic Partnership went into effect. Both companies have heralded the partnership as a new way to leverage pharmacy benefits management with a large retail pharmacy chain, with the goal of posing a serious challenge to traditional PBMs that lack a health insurer partner or a strategically-aligned retail pharmacy chain. In addition to Walgreens becoming the preferred pharmacy provider in all of Prime Therapeutics’ networks, the partnership also includes plans to form a new, joint specialty and mail order pharmacy to be owned by both Walgreens and Prime Therapeutics. Analysts estimate that the new combined company will have revenues over $12 billion. Perhaps most alarming to independent specialty pharmacies, however, is that the new company is poised to become the exclusive mail and specialty pharmacy for all of Prime Therapeutics’ plans. Thus, specialty pharmacies can anticipate strong efforts by Prime Therapeutics to begin seriously restricting access to specialty pharmacy networks.
Fortunately, however, even behemoth companies like Walgreens and Prime Therapeutics are not above the law. In many States, as well as within the Medicare Part D program, there exist a variety of “Any Willing Provider” requirements. These laws generally require a plan to admit a pharmacy into its network that is willing and able to participate on the same terms and conditions applicable to other participating pharmacies. Moreover, interpretation put out by courts and regulators has suggested that these “terms and conditions” must be reasonable and relevant, and may not be designed simply to keep other pharmacies out.
Thus, specialty pharmacies that find themselves excluded from any of Prime Therapeutics’ networks are encouraged to assert their rights. Frier Levitt routinely represents pharmacies of all kinds in challenging PBM conduct and in asserting rights under various State and Federal Any Willing Provider Laws. If you’ve faced network exclusion from Prime Therapeutics’ networks, or any other PBM’s networks, contact us today.
