Despite having mailing waivers in place since the onset of the COVID-19 waivers, recently, a major PBM has required many pharmacies to credential into the PBM’s mail order or specialty pharmacy networks in lieu of continuing in the PBM’s retail pharmacy networks.
This is troubling for many pharmacies. Undergoing mail order or specialty pharmacy credentialing involves meeting strict criteria, including technological capabilities, supply chain logistics, and adherence to stringent quality standards. In addition, pharmacies may be required to maintain certain accreditations or initiate the process of accreditation to ensure it is obtained within a certain time period. While pharmacies may embrace the opportunity to expand into mail order or specialty pharmacy services without limitation, pharmacies should also expect different terms of participation, including, often, a material difference in reimbursement rates. To illustrate, while numerous specialty pharmacies concentrate on specific ailment categories, PBMs obstinately mandate that the pharmacies possess the capacity to handle a diverse assortment of specialty drug products spanning multiple medical conditions, irrespective of whether these fall beyond the pharmacy’s primary focus. Moreover, the lack of transparent elucidation regarding participation prerequisites and the uncertain contours of network involvement further compound the issue.
To that end, if pharmacies decide not to continue with the mandated mail order or specialty pharmacy credentialing, they could face network termination or be required to adhere to retail terms of participation.
How Frier Levitt Can Help
If your pharmacy is being requested to undergo mandatory mail order or specialty pharmacy credentialing, contact Frier Levitt to speak to an attorney today. Pharmacies are also advised to understand what limitations they are subject to with respect to mailing as a retail pharmacy and are encouraged to seek counsel on such limitations.
