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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...

How Pharmacies Can Deal with Unreasonable Reimbursement Rates

A major trend in pharmacy throughout 2016 was the continued diminution of reimbursement rates for pharmacies by PBMs and Plan Sponsors, as well as the exclusion of independent pharmacies from PBMs' "restricted" provider networks. Many pharmacies have continued to see their margins shrink because of below market pricing and the PBM industry's imposition of post-adjudication "DIR Fees." In particular, the impact of "DIR Fees" on independent pharmacies has been immense,...

Cost Sharing Limitations Imposed by the Affordable Care Act May Level the Playing Field Between Specialty Pharmacy and PBMs

The enactment of the Patient Protection and Affordable Care Act (PPACA) aimed not only at expanding access to health insurance coverage, but also sought to limit out-of-pocket expenses for individuals that have health insurance. Therefore, beginning on January 1, 2014, PPACA implemented out-of-pocket expense limitations for patients with respect to in-network insurance coverage of Essential Health Benefits (EHB). These out-of-pocket expense limitations are "little known" in the healthcare industry, but...

Qui Tam Lawsuits Are Becoming an Increasingly Popular Tool to Combat False Claims Act Violations

A New Jersey federal court has ordered Nita K. Patel, Kirtish N. Patel and their two diagnostic testing companies, Biosound Medical Services, Inc. and Heart Solution P.C., to pay more than $7.75 million for knowingly submitting claims to the United States Government for falsified diagnostic testing reports. In its Complaint, the Government accused the defendants of developing a fraudulent scheme to create falsified diagnostic testing reports, forge physician signatures on...