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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...

NADAC Pricing and Aggressive PBM Prior Authorization Tactics: How Specialty Pharmacies Can Respond

Nearly every day, independent specialty pharmacies face industry changes that threaten their businesses. This year, two changes have been especially impacting – the implementation of the NADAC pricing benchmark and enhanced and aggressive prior authorization protocols and policies implemented by PBMs. Unfortunately, the implementation of the National Average Drug Acquisition Cost (NADAC) benchmark has been devastating to some pharmacies, which are often reimbursed at or below acquisition cost. Similarly, independent...

NADAC Pricing Leads to Unreasonably Low Medicaid Reimbursement: What Can a Pharmacy Do?

There has been perhaps nothing more detrimental to pharmacy margins in the Medicaid arena than the implementation of the National Average Drug Acquisition Cost (NADAC) pricing benchmark. Indeed, many pharmacies conducting business in states that utilize NADAC pricing have seen their reimbursement rates plummet, oftentimes to rates at or below acquisition cost. What's worse for independent pharmacies, NADAC pricing has seemed to gain momentum and has recently been adopted by...