Oct 29, 2023
Every year the pharmacy benefit managers (“PBMs”) your pharmacy contracts with conducts a reconciliation of certain pharmacy claims. The PBM may send you a notice directly if you carry direct contracts or may direct your PSAO to conduct the reconciliation and subsequent recoupment. These reconciliations include network-wide effective rates for Brands (BERs), Generics (GERs) and Dispensing Fees (DFERs). The calculations are measured at the aggregate level across all member pharmacies, to determine the overall network-wide liability to allocate among all member pharmacies in the network.
Generally, the pharmacy will receive a notice from the PSAO noting a dollar amount that is your pharmacy’s(ies’) share of the net aggregate owed to the particular PBM the PSAO is reconciling on behalf of. This amount for small independent pharmacies can be in the tens of thousands of dollars; in fact, reconciliations in the hundreds of thousands are not uncommon. Some pharmacies don’t read these notices as the recoupment is generally withheld from future remittances. Other pharmacies feel like there is nothing they can do to question the amount of reconciliation or the methodology as to how the PBM arrived at this dollar amount.
The tide is turning in the fight against PBM abuses. More and more states are regulating PBMs and implementing protections for independent pharmacies. The FTC issued a statement withdrawing prior PBM advocacy. Congress is investigating. There is something you can do to assist your pharmacy and join the independent pharmacy community fight against PBM abuses. PUTT is issuing an urgent request for our members and other independent pharmacies to submit BER/GER reconciliation notices you have received from your PSAO or any PBM.
Submit BER/GER Evidence to the PUTT Evidence Locker: Email Us at Evidence@TruthRx.org