Packerland
Guru
- 504
CMS has issued a warning to health insurers and pharmacy benefit managers regarding their business practices, which are affecting the financial stability of all pharmacies, particularly independent one located in rural areas.
CMS has urged them to reconsider how they reimburse these pharmacies and reminded them that the government (the same government that put these pharmacies in the position begin with) is investigating anticompetitive practices. They request
payers to establish special payment arrangements with pharmacies before a new policy in 2024 reduces upfront payments to pharmacies for dispensing medications. The CMS has delayed implementing a rule that would prevent retroactive performance-based adjustment fees, which have been a source of conflict between payers and pharmacies. Independent pharmacies have faced financial pressures and closures, especially in rural areas, partly due to reimbursement issues with PBMs. The CMS also highlighted concerns about payment arrangements discouraging vaccines, limiting contraception access, excessive prior authorization, and anticompetitive practices due to vertical integration CMS/Aetna etc.
I predict this will be a major issue moving forward especially 2025 when the maximum out of pocket for prescriptions is dropping to $2,000 per member for RX.
CMS has urged them to reconsider how they reimburse these pharmacies and reminded them that the government (the same government that put these pharmacies in the position begin with) is investigating anticompetitive practices. They request
payers to establish special payment arrangements with pharmacies before a new policy in 2024 reduces upfront payments to pharmacies for dispensing medications. The CMS has delayed implementing a rule that would prevent retroactive performance-based adjustment fees, which have been a source of conflict between payers and pharmacies. Independent pharmacies have faced financial pressures and closures, especially in rural areas, partly due to reimbursement issues with PBMs. The CMS also highlighted concerns about payment arrangements discouraging vaccines, limiting contraception access, excessive prior authorization, and anticompetitive practices due to vertical integration CMS/Aetna etc.
I predict this will be a major issue moving forward especially 2025 when the maximum out of pocket for prescriptions is dropping to $2,000 per member for RX.
