PBM Network Termination Amid COVID-19 Outbreak

Pharmacy Benefit Managers (“PBMs”) continue to put independent pharmacies under scrutiny and terminate them from PBM Networks amid the coronavirus outbreak (“COVID-19”).  PBM Network termination is especially concerning at this time given the national economic and healthcare crisis brought by COVID-19.  Meanwhile, Federal and State Agencies have issued relaxed guidelines for healthcare providers including pharmacies to ensure patient access to healthcare and to mitigate further exacerbation of the outbreak.

As we reported , Center for Medicare & Medicaid Services (“CMS”) has issued “waivers” for certain pharmacy requirements including, but not limited to, relaxing restrictions on home or mail delivery of prescription drugs and waiving prescription refill limits.  Similarly, in consideration of the patient healthcare, several State Boards of Pharmacy have announced that they will waive certain provisions of Pharmacy Law/Regulations.  For example, California Board of Pharmacy have issued a notice indicating that the Board will review requests for waivers submitted by the pharmacies on a rolling basis.  Also, Kentucky’s Governor issued an executive order expanding prescribing rights to pharmacists in light of the COVID-19 pandemic. 

However, despite the Federal and State agencies’ guidelines, PBMs will continue to monitor pharmacies and may clawback the entire amount of claims submitted by the pharmacies if such claims submission does not align with standards set forth by PBMs.  For example, will a PBM take issue with a pharmacy’s mailing of prescriptions pursuant to CMS Guidance, despite what is set forth in the Manual?  Will a PBM offer the same ability to waive patient cost-sharing that it is applying to its wholly-owned pharmacies?

How Frier Levitt Can Help

The interplay between these waivers, various agency requirements, and the terms and conditions set forth in PBM Manuals is a complicated landscape that requires experienced counsel.  In light of this, Frier Levitt is offering services to pharmacies across the county to assist in submitting requests to the various agencies to ascertain the scope and extent of the waivers and how they relate to one another.  In addition, Frier Levitt is assisting pharmacies in safeguarding against current or future scrutiny from PBMs over the pharmacies’ efforts to service their patients in these challenging times.  Because of our experience in representing hundreds of pharmacies across the country, we are often able to handle these matters on Alternative Fee Arrangement bases, helping to provide predictability and deliver value in these uncertain times.

For more information, or to explore how this recent guidance may provide opportunities for your pharmacy, contact Frier Levitt to speak with an attorney.

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