5. Steering, Clawbacks, and Retroactive Fees: This creates financial instability by design.

*One large employer group underwrote a health insurance policy with prescription coverage for their 300+ employees.  The employees found upon attempts to use the policy that the CareMark policy required them to either pay out-of-pocket or utilize a CVS/CareMark pharmacy (mail order, or nearly 100-mile average for employees to the nearest physical store).

*PBM’s hold costs out of pharmacy dispensing payments based upon patient adherence.  In other words, if a doctor writes a prescription for blood pressure medication, and the medication is not tolerated after 6 months and needs changed, the pharmacy will be penalized for the patient not picking up the medication for future periods of time until the PBM recognizes the medication is no longer taken due to months of not being filled.  Pharmacy & prescriber cannot inform PBM of discontinuation to effect any difference in reimbursement.  This is also an average across all patients filling at the pharmacy for the particular drug classification (for instance, all patients on specific drug class of high blood pressure treatments or diabetes non-insulin treatments).  Pharmacies are not allowed to enforce specific patient filling habits, nor do they want to force patients to do so, and numerous factors can affect fill rates.  Patients may receive medications through patient assistance programs, dosages may change, hospitalizations/assisted living stays may provide medications, surgeries or other procedures may cause patients to stop therapy, etc.

*Some PBM’s actually have lists of prescriptions that are considered for penalty fees if a certain percentage of patient prescriptions are filled and exist on that list.  Pharmacies not only run the risk of receiving penalty fines for patients using these medications but also run the risk of potentially losing the entire contract if the percentage of fills exceed a set level too egregiously…