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PHARMACY ALERT: Law in Puerto Rico Offers Relief for Underwater Reimbursement

On July 30, 2019, the Commonwealth of Puerto Rico passed the Pharmacy Services and Benefit Managers Regulatory Act (the “Act”), and the relevant portions of the Act took effect in November 2019. Its effects may have gone largely unacknowledged by PBMs seeking to adjust reimbursement under new addenda to their contracts. Independent pharmacies in the Commonwealth should be aware of their protection under the law and should reserve their rights before entering into any new agreements for reimbursement with a PBM.

Enacted as 2019 Puerto Rico Laws Act 82 (S.B. 218), the Act establishes a new regulatory regime over PBMs operating in the commonwealth, and aside from pricing protection, also provides fair audit and MAC regulations and prohibits retaliation and, notably, requires “just cause” for termination. The law is comprehensive and provides robust protection for pharmacies in the Commonwealth.

Of particular note is Section 8 of the Act, titled “Reimbursement for Drug Payment Below the Acquisition Cost.” That section provides the following, among other provisions:

  • If paid below acquisition cost on a drug, a pharmacy has ninety (90) calendar days from receipt of payment to appeal the claim.
  • PBMs and pharmacy benefits administrators (termed “PBAs” in the Act) and “similar entities” must provide a claim form for appeals, as well as contact information for a Spanish-fluent contact person for such claims.
  • The PBM or other entity has forty-five (45) days to process the appeal, which is deemed approved if the 45-day period expires without an answer. The pharmacy is only required to fill out the claim form and include the invoice from the pharmaceutical wholesaler stating the drug acquisition cost as proof of its claim.
  • In the event the PBM, PBA, or similar entity has paid for a product incorrectly or below Puerto Rico’s market price for any period, the Regulatory Commissioner shall publish it electronically for the benefit of pharmacies.

How Frier Levitt Can Help

These and other provisions of the Act make it a powerful tool for pharmacies not only to appeal unfair reimbursement, but also to negotiate fair reimbursement from PBMs before entering into any new contracts. Frier Levitt has years of experience negotiating contracts with PBMs and can leverage that experience and the Commonwealth’s powerful Pharmacy Services and Benefit Managers Regulatory Act to benefit your independent pharmacy in negotiating its PBM contracts. Call us today: 973-618-1660.