NCPA is advising members that some PBMs may offer reduced reimbursement for the upcoming Medicare Part D plan year (CY2023). NCPA anticipates that the terms some PBMs may offer might reimburse independent pharmacies below their product acquisition cost. Additionally, please be aware that some contracts are opt-out contracts that require a pharmacy to proactively send a specific form of notice to a PBM, sometimes within a short period of time, declining participation in the network if the pharmacy determines that the terms offered are not satisfactory. Otherwise, the PBM-proposed terms would likely go into effect for the entire 2023 Medicare Part D plan year. Part D plans and PBMs are required by law to maintain network access standards for beneficiaries. Further, PBMs are required to have "reasonable and relevant terms and conditions” for any willing pharmacy” (more background here) to participate in a Part D network, so pharmacies should review any proposed contract for issues which might adversely affect their operation. Members should make an independent business decision as to whether the proposed terms are appropriate for their pharmacy. NCPA urges member pharmacies to carefully evaluate the financial and other terms of any proposed contract and to adhere to PBM deadlines and any specific notice requirements in their contract with a PBM.
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