No Organization Likes Surprises – Especially When it Comes to PBM Contracts
Though CVS has yet to make a public statement about the claim because they haven’t been officially served with the lawsuit, company spokesman Michael DeAngelis did state that co-pays are determined by a patient's prescription coverage plan, not by the pharmacy, and that a similar lawsuit in Massachusetts was dismissed.
Plan sponsors don’t always prevail in these kinds of complaints, but situations like this are exactly why you don’t want to use a pharmacy benefit manager’s (PBM’s) standard contact language.
The details around factors such as discount programs and “usual and customary” pricing can make all the difference in how much you and your plan members pay for prescription drugs.
For example, your PBM contract should include language that the PBM will charge you for the lowest of the following pharmacy network claims (less member copayments or deductibles):
- Participating pharmacies’ usual & customary (U&C) price
- AWP discount (ingredient cost) plus the guaranteed dispensing fee, if applicable, or
- Maximum allowable cost (MAC) plus the guaranteed dispensing fee, if applicable
Ensure your PBM contract protects your interests.
Health Plans, download these best practices for contracting with your PBM, visit our website or contact us here.
Employers, download these best practices for contracting with your PBM, visit our website or contact us here
Senior Director, Payment Integrity