Pharmacy Patient Protections

In the past, pharmacy legislation has often focused on narrow, nuanced issues regarding PBM practices that hurt pharmacies and patients alike. Rather than seek to address one specific practice, NCPA has developed a set of resources that covers a course of actions employed by PBMs that are harmful to both patients and our members.

Additional accreditation and certification requirements
State board of pharmacy are charged with protecting the health and well-being of the citizens in their state. When PBMs start making decisions regarding who can practice and how they can practice, they are stepping into the domain of the state board of pharmacy and restricting access to otherwise qualified pharmacists. This has negative consequences on patient access to care and patient choice.

Anti-mandatory mail order
Pharmacy Benefit Managers own automated dispensing facilities that fill and ship prescriptions requiring 90-day supplies. The PBMs refer to them as "mail order pharmacies." However, these closed environment, robotics-driven assembly lines don’t deliver the patient benefits of a traditional pharmacy.

This document provides additional background and guidance to states looking to enact anti-mandatory mail order legislation or rules.

Pharmacy delivery service restrictions
Prohibiting home delivery hurts patients with restricted mobility and deprives them of their ability to receive their medications from their community pharmacist.

Copay clawback prohibition
Under almost all health care plans, patients are responsible for a certain level of cost sharing. With this model, the patient assumes they are paying a portion of the cost and their insurance company is paying the remainder.

The practice known as "copay clawback" turns this premise upside down. In this case, the cost of the medication is lower than the patient's copay, but the patient’s PBM instructs the pharmacy to charge the patient an inflated copay. Later the PBM "claws back" the excess from the pharmacy and keeps it for themselves.

Pharmacist/patient communication on alternative therapies
In some instances, the pharmacy's usual and customary (U&C) price is lower than the patient's copay. Typically, the pharmacy is prohibited by their PBM contract from telling a patient what the pharmacy is being reimbursed by the PBM. If the PBM inflates the patient's copay above the pharmacy's U&C pricing, the pharmacy can’t say anything unless the patient specifically asks about the cost without insurance.