Home infusion pharmacies face a unique set of challenges and requirements in providing care to patients in the comfort of their homes. This is equally true when it comes to the Medicare Part D benefit, which provides coverage for prescription drugs received by seniors who have enrolled in a Part D Plan. Federal regulations impose certain requirements incumbent on Part D Plan Sponsors and home infusion providers, alike, aimed at ensuring robust access to this important benefit. However, in practice, these regulations are not always followed, and home infusion pharmacies are not always afforded the unique treatment Congress intended. Home infusion pharmacies should be on alert regarding their Medicare Part D contracts with pharmacy benefits managers (PBMs) because, in certain cases, the PBM should offer home infusion pharmacies a contract exempting them from DIR “performance” fees. Additionally, some contracts may also be available that provide significantly higher point-of-sale reimbursements than those offered to “retail” and other pharmacies. Frier Levitt encourages home infusion pharmacies to review your Part D contracts.
The Medicare Part D Any Willing Provider Law (AWPL) requires Part D plans to offer “reasonable and relevant terms and conditions” of participation to all “similarly situated” pharmacies, as CMS has expressly stated in the Medicare Part D Benefits Manual (Part D Manual). We interpret this to mean that if a PBM offers special terms and conditions to one home infusion pharmacy, it must offer those terms and conditions to all home infusion pharmacies. Unfortunately, there is reason to believe many PBMs have failed to do so.
It has come to light that certain PBMs may be offering favorable home infusion pharmacy contracts to some, but not all home infusion pharmacies in their Part D networks, which constitutes a failure to meet their responsibilities under the Part D Manual. According to the AWPL, all home infusion pharmacies should be considered “similarly situated” with each other making it essential for PBMs to provide equal terms and conditions to all pharmacies. Offering entirely different terms and conditions to one home infusion pharmacy and not another violates the AWPL. Home infusion pharmacies should know their rights and insist on equal treatment. Some of the terms in these home infusion pharmacy contracts may include exemptions from DIR fees, more favorable rates, and other favorable terms and conditions.
Frier Levitt attorneys have extensive experience handling disputes with PBMs over DIR fees, earning our clients back millions in DIR fee awards. If your pharmacy provides a high volume of home infusion products and services, and you believe your pharmacy should be receiving a home infusion pharmacy contract from PBMs, contact Frier Levitt today to learn more about asserting your federal rights under the AWPL.
