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ALEXANDRIA, Va. – With time of the essence, the National Community Pharmacists Association is pushing Cigna’s Express Scripts, Inc., to revise contract terms to align with its obligation to offer “reasonable and relevant” terms and conditions for participation in a Medicare Part D pharmacy network, and to revise its “bonus pool fee” to align with federal policy. ESI should immediately address these concerns before more independent pharmacies close, NCPA CEO B. Douglas Hoey, pharmacist, MBA said in a letter to Adam Kautzner, president of ESI, and David Cordani, chairman and chief executive officer of the Cigna Group.
“We cannot help but note that Cigna-Express Scripts has publicly announced a desire to work with independent pharmacies and has even formed an Independent Advisory Committee in the last year,” Hoey wrote in his letter. “Unfortunately, and ironically, business conditions dictated by ESI to independent pharmacies have only gotten worse since ESI’s announcements – especially regarding Medicare Part D terms that our members tell us are out of market relative to Cigna-ESI’s competitors.”
A newer concern Hoey raised in his comments is an additional in-network per-claim “bonus pool fee” with which ESI seems to be deducting a set amount from each Part D prescription. These bonus pool deductions are pharmacy price concessions that are not transparent at the point of sale; instead, the adjustment shows up in bulk (not claim-by-claim) on the 835-payment file, also known as the Electronic Remittance Advice. This appears to be in violation of the CMS rule that requires all pharmacy price concessions to be accounted for at the point of sale, Hoey wrote, amounting “to millions of dollars that have been assessed since January 1, all to enrich ESI, while [NCPA] members wait to see if they will earn any of their money back later in the year.”
Hoey also detailed longer-term issues involving Cigna-ESI’s draconian contract terms, particularly on brand-name prescriptions, referenced by NCPA members when discussing whether they will be able to keep their business open. ESI is continuing to pay pharmacies at rates that are less than their cost to acquire prescription medicines in Part D, he wrote, violating federal law and guidance related to “reasonable and relevant” terms and conditions for participation in a pharmacy network. Additionally, he said, ESI is basing its reimbursement calculations on vague terms that result in unpredictability and inequity in payment rates, and ESI creates mass confusion with its e-faxed, opt-out adhesion contracts with tight timelines and the erroneous letters it sent to patients misrepresenting their pharmacy’s status in its network.
Hoey’s letter follows a February NCPA survey of independent pharmacy owners/managers in which almost half said that ESI was the PBM causing the most financial stress in Part D. CVS/Caremark came in at 35 percent.
“Almost one independent pharmacy a day closed its doors for good last year, a pace that’s continuing into 2024 so far. Perhaps most disturbing, almost every pharmacy owner responding to our survey is considering if they will continue to participate in Medicare next year with all of its egregious take-it-or-leave-it PBM contracts,” Hoey says. “Unless ESI and its ilk are reined in once and for all, patient drug costs will continue to rise and millions will be at risk of losing access to the care they can currently receive at their local community pharmacy. No more prescriptions at local pharmacies, nor related drug management services or other things like immunizations, health screenings, disease state management, and point-of-care testing. It would be a catastrophe, and one that could have been prevented.”
Copied on the letter were CMS Administrator Chiquita Brooks-LaSure and the chairs and ranking members of the House Energy and Commerce Committee, House Ways and Means Committee, House Oversight and Accountability Committee, and Senate Fin
