NCPA Pushes CMS for Regulations Outlining PBM Contracting Guardrails

ALEXANDRIA, Va. (Sept. 4, 2024) - With Medicare Open Enrollment starting next month, the National Community Pharmacists Association is pushing the Centers for Medicare & Medicaid Services to issue fair and common-sense contracting guardrails between Medicare Part D plans/pharmacy benefit managers and pharmacies. Medicare Part D makes up 36 percent of the average independent pharmacy's business and current contracting practices that reimburse pharmacies less than their costs to acquire medications, dispense prescriptions, and earn a reasonable profit are having a disproportionately negative effect on the solvency of pharmacies. They are also leading to questionable or even inaccurate pharmacy network information in the Medicare Plan Finder tool that allows seniors and caregivers to shop and compare Medicare Advantage and Part D plans.

Among other things, NCPA is urging CMS to require Part D plans/PBMs to notify pharmacies or their contracting entities about the pharmacies' network status for the upcoming plan year, and that the contracts themselves must be opt-in, signed and finalized prior to Oct. 1 each year; require plans/PBMs to make their standard contracts available upon request from interested pharmacies no later than the first week of June of each year when Part D bids are due to give pharmacies and their contracting entities enough time to adequately analyze and negotiate a PBM contract; require that contracts be offered anew every year, with payments and networks that cannot be changed without further negotiation and consent of all parties to the contracts; and require that plans/PBMs cannot "bundle" or "tie" participation in one network to another non-Medicare Part D network.

"If contracts are for more than one year, pharmacies find themselves in a relationship with plans/PBMs similar to the Eagles' 'Hotel California,' which they can never leave," wrote NCPA CEO B. Douglas Hoey, pharmacist, MBA, to CMS Administrator Chiquita Brooks-LaSure and Meena Seshamani, MD, PhD, CMS deputy administrator and director of the Center for Medicare. "We believe that plans/PBMs are attempting to lock our members into multiple year contracts to game CMS' pharmacy access standards in Medicare Part D."

To read Hoey's letter and NCPA's requests, click here.

###

Founded in 1898, the National Community Pharmacists Association is the voice for the community pharmacist, representing over 19,400 pharmacies that employ more than 230,000 individuals nationwide. Community pharmacies are rooted in the communities where they are located and are among America's most accessible health care providers. To learn more, visit www.ncpa.org.