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340B Contracting in an Age of DIR Fees and Predatory Pricing

The 340B program is a federal discount drug program which requires pharmaceutical manufacturers to enter into an agreement, called a Pharmaceutical Pricing Agreement (PPA), with the Secretary of the Department of Health & Human Services in exchange for having their drugs covered by Medicaid and Medicare Part B. Under the PPA, the drug manufacturer agrees to provide front-end discounts on drugs purchased by "covered entities," which typically serve the nation's...

Pharmacy ALERT: PSAO Pharmacy First Sends Notice of GER Deductions

Pharmacy Services Administrative Organization (PSAO) Pharmacy First is sending out a "Notice of GER Deductions" to pharmacies in its network advising that the pharmacy's reimbursements have been running in excess of the contracted Generic Effective Rate (GER) amount. The Notice warns the pharmacy that the monetary sum in excess of the contracted GER amount will be withheld. It is often the case that the pharmacy is without any knowledge of...

California Pharmacies Set to Suffer Retroactive Medicaid Clawbacks

California pharmacies must act now to prevent 18 months of retroactive reduction in Medicaid payments set to be collected from pharmacies in late 2018. Without taking action now, pharmacies may be unable to shoulder the burden of historical claims adjustments for all California Medicaid claims after April 1st, 2017. In 2017, the Centers for Medicare and Medicaid Services (CMS) required state Medicaid reimbursement to transition from an Estimated Acquisition Cost...

Kentucky Proposes Legislation Aimed at Increasing Medicaid Reimbursement Rates and PBM Oversight

Throughout the nation, independent pharmacies are facing lower and lower Medicaid reimbursement rates. These rates are making it harder for pharmacies to make ends meet as the rates often result in pharmacies being reimbursed at or less than their acquisition cost. In response to these unreasonable reimbursement rates, independent pharmacies have urged legislators, both at the state and federal level, to address the predatory reimbursement rates set by Pharmacy Benefit...

New Jersey’s New “Prescription Drug Patient Protection Act” Will Regulate PBMs and Limit Use of Prior Authorization

The "Prescription Drug Patient Protection Act" has recently passed both houses of the Legislature in New Jersey and is currently awaiting signature by Governor Phil Murphy. The Bill establishes a host of new requirements to be followed by PBMs offering services in the state, including certain prohibitions regarding the Prior Authorization process. If signed into law by the Governor, it could greatly impact PBMs that are currently operating in New...