A survey conducted by the National Community Pharmacists Association (NCPA) revealed that almost all independent pharmacies experience significant increase in drug acquisition cost while reimbursements are not simultaneously adjusted to reflect the increase. Often, reimbursements are adjusted but with remarkable delays. When pharmacies appeal these MAC reimbursements and delays in adjusting generic pricing, the appeals are often denied or not even considered.
(The most frequently cited generic medications for which pharmacists receive below-cost reimbursements include benazepril, clomipramine, digoxin, divalproex, budesonide, haloperidol, hydroxychroloquine, levothyroxine, methylphenidate, morphine, nystatin/triamcinolone, pravastatin, tamsulosin, and tizanidine).
A few years ago, 29 pharmacies filed an action in Pennsylvania against a major PBM to prevent unfair and below-cost MAC pricing arguing breach of contract and bad faith in carrying out contractual obligations. Because most of the pharmacies had an arbitration clause in their contracts, their cases were sent to arbitration. But one pharmacy – Lakeview Pharmacy – proceeded with litigation. Later in the proceedings, the court found that the PBM failed to promptly respond to the pharmacy’s appeals and to retroactively reimburse successful appeals.
This precedent opens a door to successfully alleging breach of contract claims against PBMs on arbitrary MAC pricing and appeals. The law firm who represented Lakeview Pharmacy considers California an ideal forum to continue the momentum. California has a strong precedent under the “Unfair Competition and Unfair Business practices” litigation as well as under California MAC law. The firm is looking for California pharmacies and pharmacy groups to step up and open an issue of the below-cost-reimbursement and reimbursement discrimination (where chains and PBM mail orders are reimbursed substantially more than independent pharmacies). Please note, the case will be based on contingency fee. Therefore, pharmacies are not required to make monetary contributions or advance costs.
If you want to know more on how you can participate, as a plaintiff or by submitting information on your reimbursements, please contact our firm. We want to reach as many pharmacies as possible, so please share this post. If we have enough pharmacies stepping up and escalating the movement across the nation – we could establish a similar precedent in California as Pennsylvania pharmacies did.