Medicare Reprimands PBMs over Apparent Prescription Drug Benefit Violations


By Kevin Schweers

On the eve of open enrollment for the 2015 plan year for Medicare Advantage and Medicare Part D drug plans, The New York Times has recounted concerns repeatedly raised by Medicare officials concerning pharmacy benefit managers (PBMs) that have inappropriately delayed or denied access to prescription drugs.

signThis is somewhat ironic because community pharmacists have for years experienced punitive audit practices conducted by PBMs or their agents, yet it is reportedly common for PBMs to restrict or limit their clients’ ability to audit them. Apparently unlike other health plans, a program the size of Medicare has the ability to audit on its own terms.

According to the Times, Medicare leaders are concerned about practices such as:

  • PBMs that “inappropriately rejected claims” for prescription drugs in 61 percent of Medicare’s audits.
  • PBMs imposed “unapproved quantity limits” on beneficiaries unnecessarily.
  • PBMs repeatedly insisted on “prior authorization” for prescription drug claims when such requirements were not appropriate.
  • Long waits for coverage decisions on drugs for which patients and their doctors asked.

A former Medicare official who now consults for insurance plans didn’t mince words. John Gorman told the Times that PBMs “know how to manage drug benefits for working-age people with commercial insurance, but they are confounded by the complex needs of seniors. Many are failing Medicare beneficiaries.”

In other Medicare news, NCPA staff has compiled a detailed analysis for NCPA members of the largest anticipated 2015 Medicare Part D drug plans. It is accessible at this link (NCPA member log in required). The resources are intended to aid community pharmacists as they assist Medicare beneficiaries during open enrollment, although they are not intended for distribution to patients. In addition, NCPA hosted a webinar on the subject, including an overview of iMedicare, a drug plan comparison tool. A recording of the webinar is available to NCPA members online here (log in required).

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