APRx Puts Medicaid PBMs on Notice
to End Deceptive, Coercive Tactics | | |
Background
The Texas Health and Human Services Commission (HHSC) is transitioning the Texas Medicaid Vendor Drug Program from a fee-for-service model to managed care. HHSC hopes to begin requiring Meidicaid patients to obtain their prescription drugs through managed care by March 1, 2012.
The managed care model is being rushed into place without any economic impact study by the state or any meaningful public comment period. The two new layers of middlemen -- managed care organizations (MCOs) and pharmacy benefit managers (PBMs) -- are offering payment rates to pharmacies that are slashed by approximately 88%. The reduced fees represent pure profit for the middlemen, as any reduction in costs is not passed on to HHSC. Pharmacies are left with the difficult choice of filling prescriptions at a loss or closing their doors. The move to managed care under such circumstances threatens greatly reduced access for vulnerable Medicaid patients and far-reaching economic harm to the independent pharmacies that serve them.
Deceptive PBM Letters Certain PBMs are using high-pressure, deceptive and misleading tactics -- such as artificial deadlines and threatened penalties -- in their pharmacy communications. These PBMs aim to satisfy the access requirements of HHSC and CMS through misleading communications. APRx will not tolerate its member pharmacies being misled into decisions that will permanently affect their businesses, vulnerable Medicaid patients and Texas communities.
APRx Takes Action The American Pharmacies' legal team evaluated various PBMs' deceptive efforts to generate enrollments in their networks, and has sent letters to two PBMs -- Navitus (see Navitus letter) and InformedRx (see InformedRx letter) -- demanding that they stop using such methods. On behalf of the independent pharmacies in Texas who received these misleading communications, APRx has demanded that Navitus and Informed Rx send a new letter to each pharmacy that received the misleading communication -- a letter informing it that there is no deadline to sign the provider agreement and that the Vendor Drug Program fee-for-service program will continue to process and reimburse claims as usual until Medicaid patients are required to obtain their medications through managed pharmacy care.
In addition, APRx has demanded that Navitus and InformedRx immediately offer each pharmacy that has received a misleading communication the option to rescind the provider agreement. Finally, APRx has demanded that Navitus and InformedRx notify HHSC that some or all of its providers were enrolled as a result of the deceptive communication and that such pharmacies should be excluded from HHSC's assessment of the sufficiency of access of Navitus and InformedRx's pharmacy networks. Should Navitus and InformedRx fail to take this corrective action, APRx intends to pursue all necessary legal action on behalf of its members.
APRx's Position on PBM Artificial Deadlines & Threats Consequently, while APRx cannot give member-specific legal advice, it is APRx's view that there is NO valid deadline for a pharmacy to sign up with the PBMs (despite any artificial deadlines stated in a PBMs' letters to you). Pursuant to their contract with HHSC, the MCOs are obligated to admit any willing pharmacy into their Medicaid network at any time so long as the pharmacy agrees to comply with the financial terms and conditions of the contract, as well as other reasonable administrative and professional terms and conditions of the contract.
Please evaluate your proposed contract carefully.
What's next? The APRx legal team continues to evaluate an appeal of our latest court decision, as well as possible additional legal actions concerning the granting of the waiver, the transition to managed care, and, of course, the deceptive efforts of various PBM's to coerce pharmacy enrollment in their networks. We will keep you informed of our continuing efforts.
Questions? Information to report about this topic? Did you already sign a contract with Navitus or Informed Rx?
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The Center for Pharmacoeconomic Studies at the University of Texas College of Pharmacy still needs your help with a survey to determine the extent to which pharmacists use social media (Twitter, Facebook, Linked In, blogs, texting, etc.) for patient education and professional development. Pharmacist response to the survey has been low and we ask that you take time to complete the survey as soon as you can.
The online survey is anonymous and takes approximately 10 minutes.
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Your APRx Board
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Vance Oglesbee, R.Ph.
Chairman Robert Kinsey, R.Ph. Vice Chairman Bruce Rogers, R.Ph. Secretary/Treasurer Lynn Everett, R.Ph. Immediate Past Chairman DIRECTORS Ray Carvajal, R.Ph. Alton Kanak, R.Ph. Michael Muecke, R.Ph. Joe Ochoa, R.Ph.
Dennis Song, R.Ph.
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| Your APRx Staff | |
Mike Gohlke President
mgohlke@aprx.org
Richard Beck, R.Ph.,
VP, Pharmacy Affairs
rbeck@TxRxCouncil.org
Laird Leavoy,
VP, Sales & Operations
lleavoy@aprx.org
Ryan Gevara
Sales Director
rgevara@aprx.org
Chris Benest
Business Dev. Manager
cbenest@aprx.org
John Foley
Business Dev. Manager
Chuck Waters
Dir. of Comm. & Member Services
cwaters@aprx.org
Paula Gray,
Assoc. of Administrative Affairs
pgray@aprx.org
General Counsel
Amanda Gohlke Fields
afields@aprx.org
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