Patients’ Pharmacy Access Relies on Fair Pharmacy Reimbursement

Background

Patients need reliable access to community pharmacies, which need fair reimbursement to stay in business. About 80 percent of drugs dispensed are generics, which pharmacists promote to help save beneficiaries and Medicare money.

Prices for many generic drugs are skyrocketing by 1,000% or more virtually overnight, yet drug plan middlemen known as pharmacy benefit managers (PBMs) may wait months to update reimbursement. That leaves independent community pharmacies with losses of $40 to $100 or more per prescription. Such losses are unsustainable any small business.

In addition, PBMs may be paying pharmacies low and charging much higher rates to health plans, including Medicare Part D drug plans. This practice of "spread pricing" was examined in a recent Fortune magazine article entitled "Painful Prescription."

Solutions

At the federal level, Congress should enact bipartisan legislation to do two things:

  1. Preserve patient access to pharmacies by ensuring their reimbursement from PBMs is updated more frequently to keep pace with actual market costs.
  2. Allow a pharmacy to know how its individual maximum allowable cost (MAC) reimbursement rates for multisource generic drugs would be determined (but not those of other pharmacies in that particular health plan's pharmacy network).

Reps. Doug Collins (R-Ga.) and Dave Loebsack (D-Iowa) have introduced H.R. 244, to implement these principles.

Sixteen states have enacted comparable legislation.

Click here to read real-world examples of the egregious prescription drug losses that threaten the viability of small business community pharmacies.

Take Action:

Consumers:

Urge your Members of Congress to support your pharmacy access by ensuring fair pharmacy reimbursement.

Pharmacists:

Engage your patients in the Fight4Rx grassroots advocacy network at www.fight4rx.org.

Share your support for #communitypharmacy. Follow NCPA on social media:

Generic Drug Losses Unsustainable for Independent Community Pharmacies

The National Community Pharmacists Association surveyed 700 community pharmacists. In the survey respondents cited many problems with patient access to medication and significant losses on filling prescriptions including the following examples:

  • We are on the brink to fail after 83 years. We cannot pay our bills. Too many Rxs we are losing money on.

  • On 9/1/14 econazole 1% cream increased 772.47%. [PBM] was notified on 9/5/14. The price increased from $19.94 to $173.87. [PBM] continued to pay around $22.50 until 1/8/15. Then raised the MAC and we were paid around $31.20. Then in February we were paid around $51.00. The lowest price that I can find this product for is $153.79

  • Digoxin tabs-went from 15/90 to 90/90 many seniors use the med. Donut hole costs go up 800%

  • We routinely lose hundreds of dollars when prices spike 500-1000% for several months.

  • MEPERIDINE 100MG TABS PRICE INCREASE TOOK EFFECT 5 MONTHS AGO - I ABSORBED A $120 LOSS ON FIVE OCCAISIONS BEFORE I TOLD THE PATIENT I COULDNT CONTINUE TO EAT THE LOSS. HE IS NO LONGER TAKING THE DRUG - OTHER STORES IN TOWN "CAN'T GET THE PRODUCT", IE, WON'T STOCK IT FOR HIM

  • Cash patients that no longer take their digoxin due to price

  • We had several patients who have left without their heart pill.

  • Desonide ointment 0.05% - patient could no longer afford the over 100 dollar price increase

  • Hydroxychloroquine 200mg tablet from $13.20 to 226.89/100

  • Chlorpromazine went from ~$200/100ct to $800/100ct and we were reimbursed for 2 months at the lower rate. Rx was for 210 tablets. We lost over $2,000 providing this necessary medication to our patient.

  • Hydroxychloroquine...patients went without, MDs furious

  • I have witnessed numerous patients choose not to pay for Doxycycline capsules due to the cost.

  • Tetracycline 500mg cost 900/100 insurance reimburse about $5. No one will stock so patient can't get it

  • Doxycycline 100mg may prescriptions unfilled or had to have doctor change prescription

  • Clomipramine 50 and 75mg increased $500 each for a patient, we provided the care. PBM refused to retroactively increase our reimbursement. $1000 loss each month for us

  • Doxycycline hyclate 100mg tablets went from a bottle of 500 costing $22.61 to a bottle of 500 costing 1238.24. Many patients without coverage have forgone their Doxycycline prescriptions despite having lime disease because of the astronomical retail cost of even a small supply of doxycycline hyclate now.

  • Carbamazepine 200mg tablet 2077% cost increase caused a significant out of pocket increase to the customer which caused them to go without medication for 2 weeks until their check showed up.

  • methylphenidate er 20mg tabs. Dispensed partial rx and remainder of medication had increased in price by $600. Lost $500 on that Rx

  • URSIDIOL 300MG IN AUGUST PRICE INCREASED FROM $29.TO $450 THIS CAUSED PEOPLE TO CUT BACK ON WHAT THEY WERE TAKING

  • These huge jumps are putting people in the ["donut hole" or Medicare coverage] gap faster

  • NURSING HOME PATIENT RECEIVING ECONAZOLE 1% CREAM 85 GRAM, PBM PAID $22 WHEN MEDICATION COSTS $320

  • Divalproic acid ER raised over 2000% in price. Patient went without medication because copy was too high. Accepted risk of increased seizure activity without drug.

  • Ursodiol 300 mg went from $30.00/100 to $450.00/100 The Medicare Part D plan raised MAC to where we were reimbursed $316.00/90 in January (we still lost $90.00, but then in February they lowered MAC back down to $89.00/90 (Now we lose over $300.00). Appealed several times, but so far appeals have been ignored.

  • Carbamazepine 200mg tablets jumped from approximately $37 / bottle to $1200 dollars. Certain plans took > 6 months to raise the MAC. Lost several thousands of dollars as I continued to provide this medicine to our special needs patients

  • A patient had a prescription for carac for skin cancer and could not afford it due to the spike in price.

  • tamsulosin 0.4mg caps, # 1000 from $ 127.49 to $ 449.99

  • 84 year old man had his Enalapril quadruple in price. Physician would not change medication due to its efficacy. Patient did not get his heart medicine refilled.

  • We have lost over $1000 in the last two months filling prescriptions for enoxaparin injections

  • Home bound patients having to wait until meds can be changed

  • Enalapril price increase has made many senior patients not get their medications

  • I am an independent rural community pharmacy. Medicare part D plans have mostly switched to MAC pricing which is costing my store hundreds and thousands of dollars a week.

  • With the spike in amitriptyline prices, I've had a handful of patients stop taking it due to increased cost. These are most Medicare D patients.

  • Clobetasol Oint 0.05% reimbursed $12.89 on acquisition of $297.72.

  • clobetasol 0.05% cream increased from $15.50 to $238.26; patient switched to another drug and experienced worsening of symptoms

  • CATARACT SURGERY PATIENT UNABLE TO AFFORD PREDNISOLONE 1% COPAY, HAD TO DELAY SURGERY

  • Elderly lady came into the pharmacy after cataract surgery, could not afford the eye drops on her insurance, she was post-op and risked loss of eyesight without medication

  • demeclocycline 150mg lost over $500 on one fill

  • In addition, a Pennsylvania pharmacist documented 100+ of the instances he experienced below-cost reimbursement over just a few months of mid-2014. Click here to view the compilation.