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Challenges Independents Face

A number of issues threaten independents’ viability and ability to provide patient care, however. Medicare part D plan sponsors and PBMs extract DIR fees from community pharmacies, usually months after a transaction rather than deducting them from claims on a real-time basis.

“These retroactive clawbacks make it difficult for community pharmacists to operate small businesses when they don’t know whether or not they will break even on a transaction until months later,” Hoey says.

PBMs are also the decision makers for all facets of pharmacy reimbursement, which consistently declines every year. There are occasions when a pharmacy’s acquisition costs to procure generic prescription drugs are subject to dramatic and sudden price spikes. But PBM corporations lag in updating Medicare administrative contractor reimbursements paid to pharmacies—sometimes for months—and continue to pay pharmacies the older procurement cost rather than the higher current procurement cost, Hoey says. This triggers huge, unsustainable losses on these prescriptions.

Another challenge is that PBMs steer patients to mail-order or to brick-and-mortar pharmacies they own. They do this through mandates, copay incentivizing, or limiting brick-and-mortar pharmacies’ ability to dispense 90-day supplies of prescriptions, Hoey says.

Furthermore, consolidation among healthcare giants has led to fewer choices for patients and plan sponsors. “Although companies claim that cost savings will benefit patients and health plan sponsors, evidence from previous consolidations suggests otherwise,