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The Importance of Licensees Updating Regulatory Agencies of Certain Events

Has something changed in your life?  Have you moved?  Did you change jobs?  Did you sell all or part of your business or hire a new licensee?  If the answer is yes, the regulatory agency that issued your professional license probably wants to know about it. Address of Record Professional regulatory agencies generally require licensees …

CMS Final Rule Phases Out PBM’s Ability to Retroactively Apply DIR Fees

CMS recently published “Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs; etc,”, effectively ending the retroactive application of direct and indirect renumeration (DIR) fees by Prescription Benefit Managers (PBM’s). DIR fees will now be required to be included in the negotiated price the patient pays at the …

Uncertainty Looms Following Supreme Court’s Overturning of Roe v. Wade

The regulatory landscape across the United States changed dramatically Friday as Dobbs v. Jackson Women’s Health Organization overturned the nearly five-decade precedent set by Roe V. Wade. In Dobbs, the United State Supreme Court held that abortion is not a constitutional right and should instead be regulated at the discretion of the individual states. The decision was met …

Scrutiny of PBMs Continue (And It’s About Time)…

Both federal and state authorities are increasing the scrutiny and regulation of Pharmacy Benefit Managers (“PBMs”). In the U.S. Senate, Senator Chuck Grassley (R – Iowa) and Senator Maria Cantwell (D – Washington) have sponsored the Pharmacy Benefit Manager Transparency Act of 2022. The bipartisan bill would empower the Federal Trade Commission to increase drug …

FTC Reverses Previous Deadlock in Pivotal Vote to Probe Pharmacy Benefit Managers’ Practices

On June 7, 2022, in a unanimous 5-0 vote, The US Federal Trade Commission reversed a previous 2-2 deadlock vote that will result in the commissions probe of pharmacy benefit managers including the top six PBMs; CVS Caremark, Express Scripts, Inc. OptumRx, Inc., Humana Inc., Prime Therapeutics LLC and MedImpact Healthcare Systems, Inc. After the …

The Profound Responsibility of the Pharmacist When Filling Prescriptions for Patients Pursuant to a Telemedicine Encounter – Even in a Public Health Emergency

Boesen & Snow recently participated as co-counsel for a pharmacy that was the subject of a Board of Pharmacy complaint related to delivering pandemic related, patient-specific medication orders written pursuant to a telemedicine encounter.  The concern of the Board of Pharmacy was whether the prescription orders were issued pursuant to a prescription order by a …

PBM Audits and Member Denied Claims: How PBMs May Be Leading Patients Down the Path to Deny Claims Submitted for Reimbursement by Your Pharmacy.

Boesen and Snow Law has observed an increasing number of PBM audits containing “Member Denied” claims including: Member Denied Paying Copayment Member Denied Receiving Medication Member Denied Requesting Medication The trend has shown that currently, Member Denials can be nearly impossible to overcome despite refuting evidence and have increasingly led to the termination of Pharmacies’ …

Shared Service Agreements in the Pharmacy Industry

The last decade has seen a rise of so-called “shared service agreements” (“SSA’s”) within the pharmacy industry. These agreements, utilized by pharmacies under common ownership and pursuant to a contract between pharmacies that are not under common ownership, enable pharmacies to work with each other to perform certain prescription dispensing tasks.  For example, one pharmacy …

New York Enacts PBM Licensing and Oversight Laws

On January 2, 2022, New York Governor Kathy Hochul announced the signing of legislation S.3762/A.1396 that seeks to regulate pharmacy benefit managers (“PBM”). PBMs doing business in New York must immediately register with the Superintendent of Insurance, be licensed by the Department of Financial Services by 2022 and renew their licenses every three years. The …

PBM Updates Aberrant Product List

Effective January 1, 2022, at least one of the major PBMs has updated language related to the billing of specific NDC numbers the PBM considers “Aberrant.” The revised list of NDCs was sent to network pharmacies and includes a list of “Practices and Trends” prohibiting dispensing activities. The revised language, while vague, creates multiple pitfalls …