PBMs have used various strategies over the years to squeeze independent pharmacies, and these tactics are on the rise as the federal government takes aim at ...
Pharmacy benefits managers are employing new strategies to squeeze independent pharmacies, even as the industry faces pressure from the federal government, which is looking for ways to curb healthcare's middlemen and preserve competition in medicine distribution.about unfair tactics used by PBMs to force them out of business, including underpaying for filled prescriptions and reimbursement clawbacks.
The three largest healthcare companies in the country have a combined market value of more than $640 billion — all of which have their own mail-order prescription service. This has caused the misaligned incentives FTC's Khan referenced, where a PBM is looking for ways to have to pay out less to the pharmacies and direct patients to mail orders.
"Some of the most common schemes include: telemarketing, generic cost manipulation, submitting claims for medications not dispensed, secondary wholesalers, and drug resale marketplaces, and billing one national drug code but dispensing another," Optum said."There’s a lot of instances where there might have been a clerical error or something that a PBM is trying to miscategorize as fraud, waste, or abuse.
PBMs are making matters worse by sending notices to patients that their pharmacies are out of network well before the deadline to rectify the issue — at day 45 out of the 90-day period, for example. This drives patients directly to the PBMs' mail-order services. A woman who never worked out until age 66 says a simple exercise routine helped her lose 50 pounds and stabilize her blood sugar