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Independent pharmacists tell council low PBM reimbursements are unsustainable, urge retroactive relief
Summary
Independent pharmacists testified that many claims were reimbursed at $0.50'$1.25 and described administrative burdens of appeals; witnesses asked LDI and legislators to seek retroactive reimbursement, stronger enforcement and clearer remittance reporting.
Multiple independent pharmacists told the Pharmacy Benefit Manager Advisory Council their businesses are suffering under current PBM reimbursement practices and urged faster, stronger enforcement of Act 4 74 and LDI's Directive 2-57.
TJ Woodard of Prescriptions to Go said he and many peers were paid as little as $0.50 to $1.25 per claim on some prescriptions since Jan. 1 and described the appeals process as time-consuming and impractical for busy owners. "If anybody can argue that a dollar 25 is fair and reasonable, I would like to see it," Woodard said, adding that NADAC plus $9 would be "a lifeline" for many generics but would not cover some high-cost brand losses.
Don Caffrey of the Independent Pharmacy Association echoed those concerns and asked the department for clearer guidance on how it derived the NADAC+9 standard versus alternate formulations (for example, NADAC plus 2% plus a separate professional dispensing fee). He urged LDI to use unfair-trade fines and market-conduct authority where the data show systematic underpayment.
What they want: Pharmacists asked for (1) expedited attorney general review on retroactivity so past underpayments can be remedied if legally allowable; (2) more aggressive market-conduct enforcement and higher fines that change PBM incentives; and (3) clearer, itemized remittance advices and annual reporting so pharmacies can see per-claim ingredient, adjustment and dispensing components.
Evidence presented: Witnesses said they had invoices and complaint batches (one pharmacist referenced several hundred invoices submitted to LDI) showing repeated underpayments; LDI staff said that such complaint evidence is used to open confidential market-conduct investigations and, if proven, can lead to regulatory actions and recoupments.
Next steps: Pharmacists asked legislators and LDI to prioritize a rapid AG opinion on retroactivity and to ensure enforcement tools are used to deter repeat violations. The council heard multiple requests for clearer reporting and for LDI budgeting to support proactive audits.
