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Little Known and Under-Utilized Tool Enables Pharmacies to Demand Network Terms and Conditions for Medicare Part D Networks

Too often, pharmacies are faced with the difficult proposition of seeking admission into Medicare Part D networks. With new and evolving pharmacy business models, along with ever-changing and contracting pharmacy networks, it can be challenging to determine the appropriate network(s) to seek access to. This can be further complicated by PBMs routinely seeking to push pharmacies into general “retail pharmacy” networks, while restricting access from networks that provide more opportunity to provide specialty and mail delivery services.

Fortunately, however, for pharmacies seeking network access into Medicare Part D networks, there is a Medicare Part D requirement for the PBM to provide a pharmacy the standard terms and conditions within two days of the request. A PBM is required to have this information on hand and available upon request. The terms and conditions provided by the PBM will allow a pharmacy to adequately decide which networks to apply to, and set a clear target for the terms and conditions necessary for network admission. This enables the pharmacy to align its business to set standards, as opposed to arbitrate “moving targets.” 

If your pharmacy is currently looking to join Medicare Part D network and would like to obtain more information from a PBM regarding its standard terms and conditions, contact Frier Levitt today to speak to an attorney.