3. Non-Negotiable, Take-It-or-Leave-It Contracts: This imbalance of power removes real competition and violates fair dealing principles.
*Most pharmacies today exist with a relationship into what is known as a Pharmacy Services Administrative Organization, or PSAO, that helps “negotiate” contract terms with PBM’s. Most “negotiations” today exist as a review of what is given to the PSAO, and whether the PSAO feels members can financially sustain such a contract. Then, contracts are either accepted or refused.
*Common PSAO refused contracts are then offered to individual pharmacies, attempting to make the PSAO sound as if they are the non-negotiators in the common mix. Pharmacies are told if they do not sign, they simply lose access to any patient with that parent PBM’s plan(s), and too many unfortunately sign anyhow out of fear of not being able to take care of their community. This often leads to numerous of these losses on prescriptions, which has led to numerous pharmacy bankruptcies and closures.
*PBM’s continue to “offer” contracts that have so much legal language, numerous possible payment models (AWP-minus, MAC-based, and cost-plus; each may vary by Brand VS Generic or drug category types, day supply, etc.), and withhold the potential to change from one payment model per drug as best fits the PBM’s desires at any given time. Pharmacies dispense hundreds to thousands of medications (especially when considering variety of manufacturers for the same medications), and cannot verify each one in a timely or economical fashion based upon each contract given by PBM’s. These contracts are designed to “drown” pharmacies in paperwork, and create a sense of confusion, in an effort to get a signed contract and operate as they wish afterward.
*Insurances often demand pharmacies to operate with specific operations that essentially create pharmacies as a “police” for prescribing habits. The pharmacy staff often has to demand specific therapies, require specific diagnosis codes, alter dosages or day supply, and any number of other requirements to inform prescribers just to get coverage of therapy for patients. Most of these decisions are based solely off of financial reasoning rather than clinical experience and knowledge, which occasionally creates hardships for patients, as well. Examples of this include where PBM’s receive more kickback from manufacturers of Brand-Name medications instead of the cheaper generic option, so patients must receive the Brand-Name medication, often at a higher copayment than the generic, which also causes a higher expense value tagged to that patient’s health (not because of patient desire, but solely because of that of the PBM’s purse-strings).
*Newest edition just in today: a newly established component of the business operation reached out to the third-party contracting group to become part of the network for patients to utilize. The third-party payer denied after “careful consideration of the application” stating that there was sufficient availability for state-mandated minimums for patient access. Not giving patients a choice, not even providing an opportunity to review a crappy contract, just denied. No say in the matter, no issue with the application, just that we don’t want to add you into our network because we have “sufficient sufficient network of contracted providers to meet the needs of Medica members and State-mandated access and availability criteria.” Wow – nice to hear even requesting access gets denied because an insurance company doesn’t want to allow patient choice, just what they have setup as their network to date…