Survey of Community Pharmacies. Impact of Pharmacy Benefit Manager (PBM) Contracting and Auditing Practices on Patient Care.

Transcription

1 Survey of Community Pharmacies Impact of Pharmacy Benefit Manager (PBM) Contracting and Auditing Practices on Patient Care Wisconsin The Patient Choice and Pharmacy Competition Act of 2011 (H.R. 1971/S. 1058) would make several reforms to the unregulated Pharmacy Benefit Management (PBM) marketplace. These reforms would help community pharmacies serve patients and assure that there is a strong, accessible community pharmacy network. Among other provisions, the bill would require a minimum level of reimbursement transparency in the contracts that PBMs have with pharmacies for Part D and commercial insurance plans. For generic drugs, pharmacies generally don t know how much they will be reimbursed or when it will change. The bill would also make PBM auditing practices more focused on fraud rather than administrative and technical issues and make these audits more consistent among PBMs. This survey provides important information to policymakers regarding the challenges that over 1,800 pharmacies nationally report having with PBMs. This survey was conducted between June and July Attached is the data for the State of Wisconsin. 4 pharmacies from the State of Wisconsin participated.

2 Part I Transparency of Generic Drug Reimbursement in PBM Contracts I - A provision of H.R would require PBMs to disclose greater information to pharmacies in contracts regarding MAC reimbursement for generics. In a typical PBM/pharmacy contract, how much information or specificity is usually given regarding either how MAC pricing for generics is determined (methodology) or how often these prices will be updated? Transparency of MAC Pricing None Minimal Moderate Satisfactory Very Satisfactory II - Have you ever used or tried to use a PBM s MAC appeal process? Use of MAC Appeal Process 4.2% Yes No 95.8% III - If you answered yes, did you find the process or overall experience to be: MAC Appeal Process Experience 4.2% Very unsatisfactory/burdensome Satisfactory Positive 95.8% N/A

3 Part II PBM Auditing Practices of Community Pharmacies IV - Several provisions of H.R would reform the manner in which PBMs could conduct audits. How often is extrapolation used in a PBM pharmacy audit? Frequency of PBM Extrapolation in Audit Process 4.5% 9.1% 36.4% Never Sometimes Regularly Always V - Which PBM typically conducts the most aggressive audits? Most Aggressive PBMs Related to Auditory Practices 8.3% 16.7% CVS/Caremark 12.5% 4.2% Medco ExpressScripts 58.3% All about the same Other (please specify) VI - In general, how many years back does a PBM go when auditing your pharmacy s claim data? PBM Audit Look-Back Period 16.7% 41.7% 41.7% 1-2 years back 2-3 years back 3 years or more

4 VII - How consistent are the auditing requirements from PBM to PBM? Consistency of Audit Practices Among PBMs 30.4% 69.6% Not consistent at all Moderately consistent Very consistent VIII - How often do PBM auditors require (and accordingly harshly penalize pharmacies for even minor noncompliance) recordkeeping requirements that go above and beyond what is required under state or federal law? PBM Recordkeeping Requirements in Excess of State/Federal Law 17.4% Never 34.8% Often Always 47.8% Sometimes IX - How significantly are PBMs reimbursement and auditing practices affecting your ability to provide patient care and remain in business? PBM Audit Practices Impact on Patient Care 8.3% Very significant 45.8% Significantly 45.8% Not at all

5 Please provide brief examples of the most egregious PBM audit examples you have experienced in your pharmacy. We didn't have the doctors DEA number written on the hard copy even though the script was written for a non-controlled substance. We wrote DAW=2 on face of a prescription, the PBM recouped all payments because it needs to say "brand requested by patient." We had a > $850 pain prescription that we provided that always had been every 8 hours. We had one month that indicated TID (3 times daily). We processed it every 8 hours to maintain continuity with patient. The PBM attempted to recoup the full amount!! The worst one lately is a patient with chronic pain that takes a large dose of Oxycontin. The dose never changes and he doesn't try to get it early. His PBM has done a desk audit on this Rx every month since Feb. Nothing is ever wrong, but they keep trying. At what point does this become harassment and not a search for Fraud, Waste, and Abuse? The most outrageous was the time we lost signatures, had the patient attest to receiving the meds, and the doctor also wrote letters saying the patient was on the meds. The PBM didn t care, no signatures, no $$$$. We lost over $6,000.