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Biosimilars: Good or Bad For Independent Specialty Pharmacies?

The recent developments in the Biosimilar marketplace are potentially positive for pharmacies able to acquire and bill for biosimilars and navigate complex State regulations. Increased competition in biologic products is expected to improve availability and lower acquisition costs for specialty pharmacies, bolstering their bottom line and providing patient choice of drugs and pharmacies. But first, what are biosimilars? While most drugs are chemical compounds that are easily copied by generic...

Aetna Found in Violation of the Federal Any Will Provider Laws

With more and more PBMs and insurers owning their own Specialty Pharmacies, independent Specialty Pharmacies are being unfairly excluded from restrictive networks. However, a recent decision helps level the playing field, at least partially. The Centers of Medicare & Medicaid Services (CMS) has found that Aetna violated the Federal Any Willing Provider Law (AWPL) after Aetna denied network admission to qualified pharmacies. CMS entered an “Order” compelling Aetna to modify its behavior....

Specialty Pharmacy: Pitfalls when Helping Physician Offices With Prior Authorizations

A joint federal and state investigation, stemming from a whistleblower complaint, has recently resolved resulting in a $10 million civil fine for a New York specialty pharmacy for submitting false information to obtain prior authorization for specialty medications, among other alleged fraudulent activity. Some insurance companies require a prior authorization before covering certain medication. Some medications that require prior authorizations include: Specialty or high-cost medications Brand name medicines that have...

Restricted Pharmacy Networks Increase Costs to Health Care System and Patients

Independent Specialty Pharmacies (SPs) face a multitude of headwinds. Some drugs they want to purchase are “limited distribution drugs” (LDDs), meaning the manufacturer or wholesaler will not sell to the independent pharmacy because of deals with PBMs. PBMs control and decide which independent pharmacies, if any, get admitted into pharmacy networks. Most PBMs own their own specialty pharmacies, and have an economic incentive to exclude independent SPs that present legitimate...

Medicare Advantage Conflict with United Healthcare Moves to Mediation

In a case that can affect physicians across the country, a federal appeals court in New York City directed United Healthcare and two Connecticut Medical Societies to participate in mediation in an attempt to settle a lawsuit that arose after United Healthcare unilaterally terminated more than two thousand physicians from its Medicare Advantage network in 2013 through a contract amendment. Previously, a federal district court in Connecticut granted a temporary...