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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 …

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 …

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 …

PSAO’s network of pharmacies will no longer be part of TRICARE’s pharmacy network

Beginning on December 15, 2021, a major PSAO’s network of pharmacies will no longer be part of TRICARE’s pharmacy network, which is managed by Express Scripts, due to a contract dispute between TRICARE and the PSAO. TRICARE members currently receiving prescriptions from affected Pharmacies have already received notification from TRICARE of the upcoming change. If …

PSAO TRICARE Dispute

Pharmacies to Terminate from TRICARE Networks Effective December 15, 2021.  Beginning on December 15, 2021, a major PSAO’s network of pharmacies will no longer be part of TRICARE’s pharmacy network, which is managed by Express Scripts, due to a contract dispute between TRICARE and the PSAO. TRICARE members currently receiving prescriptions from affected Pharmacies have …

PBM’s Continue Fight Against State Regulation

Pharmacy Benefit Managers (PBMs) are continuing to fight against state regulation. On Tuesday, the Pharmaceutical Care Management Association (PCMA) filed a new brief with the Eighth Circuit Court of Appeals in opposition to North Dakota Century Code sections 16.1 and 16.2. In 2017, the North Dakota passed legislation to regulate PBM practices including limiting the …

Board of Pharmacy Investigations: How Your PBM Audit May Put You in Hot Water with The State Boards of Pharmacy

PBM Audits commonly review prescription hard copies, signature/delivery logs, drug invoice purchases, proof of copayment collection, proof of prescriber/patient relationship, patient consent to fill, and non-resident state licensure. PBM Audits are just one of the many hurdles your pharmacy will inevitably face while you strive to serve patients. Poor audit findings lead to extensive financial …

Patient Copayments and the Use of Manufacturer Coupons

How Saving a Patient Money can Cost Your Pharmacy the Entire Paid Claim Amount or Worse, Your Pharmacy’s PBM Contract. Most who have worked in a pharmacy for some time can remember the Purple Pill Card, the Nexium Savings Coupon with the catchy name and bright purple colors. Not only did this program have catchy …

PBM Aberrant Product Lists: The Aberrant NDC and Percentage Billed Compared to Total Volume is Only Part of the Issue

Billing of Aberrant NDCs Beginning in January of 2020, at least one of the major PBMs began monitoring its network pharmacies for the billing of specific NDC numbers the PBM considered “Aberrant”. The list of NDCs was sent to network pharmacies in November of 2019 and has since been updated in November of 2020. The …

Supreme Court Victory for States and Independent Pharmacies

With the national conversation discussing a Supreme Court of the United States (SCOTUS) that is often highly politicized and characterized as divided, it should be comforting to the independent pharmacy community to know that SCOTUS issued a unanimous, 8-0 (Justice Barrett did not participate in this decision) decision in the case of Rutledge v. PCMA. …