Pharmacy DIR Fees
Retroactive pharmacy DIR fees are the top concern for independent community pharmacists. Part D plan sponsors and pharmacy benefit managers extract direct and indirect remuneration (DIR) fees from community pharmacies, usually months after a transaction, rather than deducting them from claims on a real-time basis. Those retroactive clawbacks make it extremely difficult for community pharmacists to operate their small businesses when they have no idea whether they'll break-even on a transaction until months later.

Generic Price Transparency
Generic prescription drugs account for over 80 percent of medications dispensed by community pharmacies, yet there is little transparency in how they are priced in federal health programs by pharmacy benefit managers. Through hidden maximum allowable cost lists, PBMs can charge federal health programs high rates while paying much lower reimbursement rates to independent community pharmacies. To access patients, independent community pharmacies must accept take-it-or-leave-it contracts, which let PBMs dictate MAC reimbursement rates that are often below-cost or fail to keep up with inflation.

Community pharmacies provide cost-saving medication and pharmacy services to millions of Medicare Part B and D patients. Congress and the Centers for Medicare and Medicaid Services (CMS) are making changes to the program all the time. This section provides background on important changes that community pharmacists should know about and on NCPA's efforts to ensure pharmacists can serve their patients and receive appropriate reimbursement for their services.

Any Willing Pharmacy
Medicare beneficiary access to prescription drugs is impeded by mandates from insurance middlemen (pharmacy benefit managers or PBMs) that effectively dictate which pharmacy to use based on exclusionary "preferred pharmacy" arrangements between PBMs and, often, Big Box or mail order pharmacies. Independent community pharmacies are not allowed to participate in some of these arrangements, even if they offer to accept the Part D plan's same contract terms and conditions. This can raise access issues for patients in underserved and rural areas in which independent community pharmacies are predominantly located, which means seniors in these communities often face either higher copays or trips of 20 miles or more to a "preferred" pharmacy.