In 2018, CMS proposed a Medicare rule that would eliminate retroactive DIR fees. One of the rationales for the rule was a colossal growth of DIRs between 2010 and 2017. During this period of time, DIRs grew by 45,000%.

As a result of this aggressive “performance enforcement” by PBMs, many pharmacies are reimbursed below cost

Last Thursday, a federal judge dismissed a lawsuit brought by pharmacies alleging that Express Scripts, Inc. (ESI) used prescription data to forcibly switch patients from their retail pharmacies to ESI’s own mail-based pharmacies. The judge ruled that ESI used the patient data appropriately under the agreements with the pharmacies.

Pharmacies brought claims against ESI for

Several PBMs now require their in-network pharmacies assisting prescribers with Prior Authorizations (PAs) to have written policies and agreements with the prescribers on how PAs are prepared and submitted.

Preparing PAs is a time-consuming and tedious process. Often, prescribers are not willing to invest their staff’s time and resources into preparing and submitting them. To

I have previously covered a case of HM Compounding Services LLC, which sued Express Scripts for contractual termination. To remind, Express Scripts terminated the pharmacy for misrepresenting during a re-credentialing process that it never waived or discounted member copayments. In return, HM sued Express Scripts asserting various statutory and common law claims. See my blog

Anthem has announced a launch of its own PBM – IngenioRx. The decision came shortly after Cigna’s acquisition of Express Scripts, which provided pharmacy services to Anthem’s members since 2009. Due to the merger, Anthem decided to terminate the contract with Express Scripts. It anticipates that operating its own PBM will result in annual savings

On Wednesday, President Trump signed bipartisan legislation that would ban so-called “gag clauses” and allow “pharmacists to tell consumers when they could actually save money by paying the full cash price for prescription drugs rather than using health insurance with large co-payments, deductibles and other out-of-pocket costs.” The New York Times reports. Pharmacists “say

Approximately 20 pharmacies across Ventura county filed a lawsuit against their Pharmacy Services Administrative Organizations (PSAOs) – Arete, Elevate, and Leadernet – for allegedly conspiring with OptumRx in reducing reimbursement rates.

The pharmacies allege that PSAOs owe fiduciary obligations to independent pharmacies to protect their interests against PBMs. PSAOs allegedly failed to negotiate acceptable rates

A new litigation is brewing up against OptumRx’s arbitrary MAC pricing. A recent case was filed by 29 pharmacies against OptumRx in Pennsylvania, arguing breach of contract and bad faith in carrying out its contractual obligations. OptumRx filed a motion to dismiss and to compel arbitration. As a result, 28 pharmacies were sent to arbitration,

Audits of healthcare providers are inevitable. Negative findings and allegations of overpayment are almost certain too. Because of voluminous records to be reviewed and scrutinized, auditors use extrapolation, reviewing only a snippet of all claims submitted. If any of the claims reviewed do not comply with applicable regulations and generally accepted practices – or contain