Frier Levitt partner Jesse Dresser is featured in Specialty Pharmacy Continuum’s article, “Legal Challenges Help When Reimbursement Rates Are Underwater.”
Despite the 2024 Medicare Part D reform ending post–point-of-sale DIR fees, many pharmacies continue to face steep reimbursement cuts from PBMs—some seeing up to a 15% drop, Jesse noted in the article. However, he highlights that recent arbitration victories challenging PBM practices demonstrate that pharmacies can successfully push back against unfair reimbursement tactics.
Jesse further discusses Express Scripts’ reimbursement models as an example and outlines key challenges pharmacies encounter when facing PBMs. The article also details several victories over DIR fees and Jesse’s advice for pharmacies to review prior years’ DIR fees to potentially recover losses.
“Consider using arbitration and appeals to force the PBMs to the table, to at least have a discussion about rates and potentially explore where there could be claims,” he advises.
Jesse also explores Medicare Part D rules and the implications of the recent federal budget reconciliation bill on pharmacy reimbursement. The legislation requires pharmacies to take part in the NADAC survey to help set Medicaid reimbursement rates, but a provision that would have banned PBMs from engaging in Medicaid managed care spread pricing was removed from the bill at the last minute.
Read the full article here: https://www.specialtypharmacycontinuum.com/Policy/Article/10-25/Legal-Challenges-Help-When-Reimbursement-Rates-are-Underwater/78391
