As the plan year changes, many PBMs update their reimbursement rates and pricing structures for their various plans. Express Scripts has begun to release reimbursement rates applicable to specialty pharmacies, and many pharmacies are finding that rates are so low that reimbursement will not even cover the costs to acquire the medication.
In late 2016, Express Scripts began circulating a specialty provider questionnaire and application to pharmacies that have been identified as a pharmacy that dispenses specialty medication, requiring both an application fee and inspection fee. Additionally, the application required proof of accreditation from at least two accrediting bodies, among other requirements.
Pharmacies nationwide were forced with a decision to pursue costly accreditation or eventually lose the ability to dispense specialty medication. For pharmacies that decided to move forward with Express Scripts accreditation, the pharmacy bore these costs without knowing the ultimate reimbursement rates on specialty medications.
Recently, pharmacies have begun to receive reimbursement rates offered by Express Scripts as part of their specialty network. Preliminary analysis shows that the offered reimbursement rates will not even cover the cost to acquire specialty medications. This leaves pharmacies in a tenuous position of either servicing their patients, yet losing money for each and every claim for particular medications, or being removed from Express Scripts’ networks.
Frier Levitt has represented pharmacies against numerous PBMs and payors to challenge the legality of offering unreasonably low reimbursement rates. Contact us today to speak to an attorney.
