Key pharmacy industry players have joined a coalition that has launched a project to ensure "fair and reasonable" pharmacy audit standards for Medicare Part D prescription drug claims.

PBM Reform Coalition, Pharmacy Choice and Access NOW, PCAN, pharmacy audit standards, Medicare Part D, prescription drug claims, pharmacy benefit management companies, Dennis Wiesner, National Association of Chain Drug Stores, National Community Pharmacists Association, Food Marketing Institute, Walgreen Co., H-E-B, GeriMed, Omnicare, PharMerica, Medicare Prescription Drug Program Integrity and Transparency Act, S. 867

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Pharmacy industry coalition takes aim at PBM audits

July 9th, 2013

WASHINGTON – Key pharmacy industry players have joined a coalition that has launched a project to ensure "fair and reasonable" pharmacy audit standards for Medicare Part D prescription drug claims.

Announced Tuesday by Pharmacy Choice and Access NOW (PCAN), the PBM Reform Coalition seeks to protect patients and pharmacies from what its members call "unfair audit conduct and practices of some pharmacy benefit management companies" and to make sure that audits are performed "with integrity and with adequate due process."

The project also calls for federal legislation to address what the coalition describes as "inconsistent and nontransparent reimbursement rates" as well as to address alleged improper use of patient information.

Besides PCAN, the PBM Reform Coalition members include the National Association of Chain Drug Stores (NACDS), the National Community Pharmacists Association (NCPA), the Food Marketing Institute (FMI), Walgreen Co., H-E-B, GeriMed, Omnicare and PharMerica. PCAN is a national coalition of consumers, local businesses and pharmacists aimed at supporting quality and affordable health care and pharmacy services for patients.

"Without sufficient regulation or oversight, some PBMs have been largely playing by their own rules, engaging in questionable business practices that are hurting taxpayers as well as patients and their pharmacies. And it's time for this to stop," coalition spokesman Dennis Wiesner, senior director for privacy, pharmacy and governmental affairs at H-E-B, said in a statement. "We look forward to working with policymakers and others to advance appropriate reform measures that establish standards that protect all parties — measures that keep health care costs down, preserve patient choice and allow pharmacies to remain focused on their No. 1 priority: providing accessible quality health care to their patients."

Describing PBMs as "largely unregulated drug middlemen," the reform coalition said that PBMs came about to help control the cost of drug coverage but, as these companies grew in size, their business model has "gone from one aimed at helping insurance plans and employers realize cost savings to one primarily aimed at maximizing profits." The coalition noted that this change "has resulted in questionable conduct that has had a negative impact on community pharmacies and the patients they serve."

The PBM Reform Coalition said it will provide examples of the negative impact of improper audit practices by some PBMs that demonstrate the need for federal legislation.

"With health care costs on the rise, most in the industry are doing whatever they can to keep costs down for patients and providers. Meanwhile, some PBMs haven't skipped a beat and continue using the system to increase their own profits," added Wiesner, a 40-year community pharmacy veteran and current vice president of the Texas State Board of Pharmacy. "This type of behavior is ultimately destructive to patients as well as community pharmacies and the essential health care services they provide. It's unacceptable, and reform is needed now."

As part of its launch, the coalition announced its support for The Medicare Prescription Drug Program Integrity and Transparency Act (S. 867), legislation that it said creates PBM fair audit standards, ensures transparency of payment methodology to pharmacies and requires that recoupment of funds via audits are returned to Medicare. The coalition is calling on members of Congress to support the bipartisan bill.