Starting January 1, 2026, pharmacies will be reimbursed under a different model for dispensing certain Part D Medicare drugs. These changes are a part of the implementation of the Inflation Reduction Act of 2022 (P.L. 117-169), which provides Medicare the ability to directly negotiate the prices of certain high expenditure, single source drugs without generic
I remember times when pharmacies were able to prepare and submit prior authorizations (PAs) on behalf of the prescribers. Then, gears shifted and pharmacies were allowed to fill out PAs but not to submit them. Nowadays, the landscape is much stricter and pharmacies are only allowed to prepopulate some information, such as patients’ data. Adding
On July 26, 2024, the California Department of Healthcare Services (“DHCS”) – which administers California’s Medicaid program – sent Notices of Medi-Cal Desk-Audit (“Audit”) to numerous California pharmacies. It appears that pharmacies that bill expensive specialty medications to Medi-Cal are subjects of these audits.
The Audit requests an overwhelming amount of information: from business ownership/
Earlier this year, CMS issued its Medicare Part D Final Rule addressing DIR fees, among other things. It is important to remember that the rule does not eliminate DIR fees but moves them to the point of sale. The rule becomes effective January 1, 2024, meaning that the pharmacies will face a DIR cliff when
Earlier this year, the Senate passed the Inflation Reduction Act (a.k.a. Build Back Better Act) which was heavily covered in press. I will only focus on what the Act has in store for pharmacies and will highlight the most important provisions for the pharmacy industry.
The Act – at its core – gives CMS ability
The United States Attorney’s Office for Southern District of Florida has recently announced a settlement with three Florida pharmacies to resolve allegations that they fraudulently used collaborative practice agreements (“CPAs”) to bill federal health care programs for unlawfully prescribed medications.
In its press release, the governments explains that “A collaborative pharmacy practice agreement is
Back in 2017, the California Department of Healthcare Services (DHCS) approved a new methodology – National Average Drug Acquisition Cost (NADAC) – for reimbursing pharmacies for their drug cost. NADAC prices significantly reduced pharmacy reimbursements. See a related blog post.
For technical and financial reasons, the DHCS has not implemented the new reimbursement methodology until
I receive many questions regarding the transition to Medi-Cal Rx (a new California Medicaid program for processing pharmacy claims). The Department of Healthcare Services has just announced its Medi-Cal Rx training program for pharmacies and prescribers. If you bill Medi-Cal, I strongly suggest that you take advantage of this resource.
The training consists of three
The announced Medi-Cal Rx implementation date, which was initially set for April 1, 2021, is postponed. (See a related Blog Post).
Magellan Haelth, Inc – a PBM that will administer the program – is in the process of being acquired by Centene Corporation. Centene operates managed care plans and pharmacies that participate in the
The California Department of Healthcare Service (DHCS) has just posted an update regarding Medi-Cal Rx transition (See Related Blog Post). In anticipation of this transition, there are some early cutoff activities that California pharmacies should note: